AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (49)

•Diagnostic Errors (35)

•Identification Errors (22)

•Discontinuities, Gaps, and Hand-Off Problems (106)

•Fatigue and Sleep Deprivation (26)

•Medication Safety (211)

•Medical Complications (76)

•Nonsurgical Procedural Complications (26)

•Surgical Complications (76)

•Transfusion Complications (4)

•Psychological and Social Complications (27)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (12)

•Central and South America (1)

•Europe (31)

•North America (791)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (36)

•Active Errors (151)

•Latent Errors (81)

•Near Miss (15)

Approach to Improving Safety

•Quality Improvement Strategies (288)

•Legal and Policy Approaches (76)

•Error Reporting and Analysis (201)

•Communication Improvement (210)

•Human Factors Engineering (138)

•Teamwork (83)

•Specialization of Care (81)

•Logistical Approaches (71)

•Culture of Safety (146)

•Technologic Approaches (137)

•Education and Training (203)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (652)

•Health Care Executives and Administrators (770)

•Non-Health Care Professionals (295)

•Patients (10)

Setting of Care

•Hospitals (585)

•Psychiatric Facilities (1)

•Residential Facilities (8)

•Ambulatory Care (51)

•Outpatient Surgery (4)

•Patient Transport (4)

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COMMENTARY

Development of a modified early warning score using the electronic medical record.

Albert BL, Huesman L. Dimens Crit Care Nurs. 2011;30:283-292.

COMMENTARY

Clinical nurse specialists as leaders in rapid response.

Jenkins SD, Lindsey PL. Clin Nurse Spec. 2010;24:24-30.

COMMENTARY

Rapid response systems: from implementation to evidence base.

Sarani B, Scott S. Jt Comm J Qual Patient Saf. 2010;36:514-517.

COMMENTARY

Using an advanced practice nursing model for a rapid response team.

Benson L, Mitchell C, Link M, Carlson G, Fisher J. Jt Comm J Qual Patient Saf. 2008;34:743-747.

COMMENTARY

Intrahospital transport to the radiology department: risk for adverse events, nursing surveillance, utilization of a MET and practice implications.

Ott LK, Hoffman LA, Hravnak M. J Radiol Nurs. 2011;30:49-52.

COMMENTARY

Implementation of a rapid response team: a success story.

Scott SS, Elliott S. Crit Care Nurse. 2009;29:66-75.

COMMENTARY

Identified safety risks with splitting and crushing oral medications.

Paparella S. J Emerg Nurs. 2010;36:156-158.

COMMENTARY

Implementing a rapid response team: a practical guide.

Garretson S, Dip HE, Rauzi MB. Nursing. 2008;38:56cc1-56cc3.

COMMENTARY

Evolution of a rapid response system from voluntary to mandatory activation.

Jones CM, Bleyer AJ, Petree B. Jt Comm J Qual Patient Saf. 2010;36:266-270.

COMMENTARY

Rethinking rapid response teams.

Litvak E, Pronovost PJ. JAMA. 2010;304:1375-1376.

COMMENTARY

A performance improvement plan to increase nurse adherence to use of medication safety software.

Gavriloff C. J Pediatr Nurs. 2012;27:375-382.

COMMENTARY

Do not put medication safety "on hold" with boarded patients.

Paparella S. J Emerg Nurs. 2010;36:347-349.

COMMENTARY

Medical emergency team implementation: experiences of a mentor hospital.

Jamieson E, Ferrell C, Rutledge DN. Medsurg Nurs. 2008;17:312-316, 323.

COMMENTARY

Preventing sentinel events caused by family members.

Wall Y, Kautz DD. Dimens Crit Care Nurs. 2011;30:25-27.

COMMENTARY

Eliminating preventable death at Ascension Health.

Tolchin S, Brush R, Lange P, Bates P, Garbo JJ. Jt Comm J Qual Patient Saf. 2007;33:145-154.

COMMENTARY

Failure to rescue in neonatal care.

Gephart SM, McGrath JM, Effken JA. J Perinat Neonatal Nurs. 2011;25:275-282.

COMMENTARY

Is the drug shortage affecting patient care in your critical care unit?

Alspach JG. Crit Care Nurse. 2012;32:8-13.

COMMENTARY

Bedside shift report improves patient safety and nurse accountability.

Baker SJ. J Emerg Nurs. 2010;36:355-358.

COMMENTARY

Revitalizing an established rapid response team.

Genardi ME, Cronin SN, Thomas L. Dimens Crit Care Nurs. 2008;27:104-109.

COMMENTARY

The growth of rapid response systems.

Steel AC, Reynolds SF. Jt Comm J Qual Patient Saf. 2008;34:489-495.

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