AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (109)

•Diagnostic Errors (139)

•Identification Errors (87)

•Discontinuities, Gaps, and Hand-Off Problems (305)

•Fatigue and Sleep Deprivation (67)

•Medication Safety (732)

•Medical Complications (260)

•Nonsurgical Procedural Complications (77)

•Surgical Complications (300)

•Transfusion Complications (13)

•Psychological and Social Complications (123)

Origin/Sponsor

•Asia (10)

•Australia and New Zealand (25)

•Europe (82)

•North America (2549)

Resource Types

•Clinical Guideline (6)

•Journal Article (1832)

•Legislation/Regulation (44)

•Meeting/Conference (22)

•Newsletter/Journal (11)

•Newspaper/Magazine Article (340)

•Press Release/Announcement (24)

•Special or Theme Issue (44)

•Tools/Toolkit (47)

•Web Resource (85)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (552)

•Active Errors (414)

•Latent Errors (142)

•Near Miss (55)

Approach to Improving Safety

•Quality Improvement Strategies (641)

•Legal and Policy Approaches (325)

•Error Reporting and Analysis (855)

•Communication Improvement (860)

•Human Factors Engineering (329)

•Teamwork (198)

•Specialization of Care (155)

•Logistical Approaches (170)

•Culture of Safety (320)

•Technologic Approaches (396)

•Education and Training (487)

Clinical Areas

•Allied Health Services (8)

Target Audience

•Health Care Providers (2400)

•Health Care Executives and Administrators (2088)

•Non-Health Care Professionals (888)

•Patients (292)

Setting of Care

•Hospitals (1441)

•Psychiatric Facilities (11)

•Residential Facilities (48)

•Ambulatory Care (284)

•Outpatient Surgery (34)

•Patient Transport (21)

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BOOK/REPORT

Risk Management Pearls on Disclosure of Adverse Events.

Amori G. Chicago, IL: American Society for Healthcare Risk Management; 2006.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion #520: disclosure and discussion of adverse events.

ACOG Committee on Patient Safety and Quality Improvement and Committee on Professional Liability. Obstet Gynecol. 2012;119:686-689.

REVIEW

Disclosing harmful medical errors to patients.

Gallagher TH, Studdert D, Levinson W. N Engl J Med. 2007;356:2713-2719.

COMMENTARY

A mediation skills model to manage disclosure of errors and adverse events to patients.

Liebman CB, Hyman CS. Health Aff (Millwood). July/Aug 2004;23:22-32.

BOOK/REPORT classic

When Things Go Wrong: Responding to Adverse Events.

A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.

STUDY

How does routine disclosure of medical error affect patients' propensity to sue and their assessment of provider quality?: Evidence from survey data.

Helmchen LA, Richards MR, McDonald TB. Med Care. 2010;48:955-961.

BOOK/REPORT

Disclosure of unanticipated events: creating an effective patient communication policy (part 2 of 3).

Chicago, IL: American Society of Healthcare Risk Management; 2003.

REVIEW

Narrative review: do state laws make it easier to say "I'm sorry?"

McDonnell WM, Guenther E. Ann Intern Med. 2008;149:811-815.

BOOK/REPORT

Sorry Works! 2.0: Disclosure, Apology, and Relationships Prevent Medical Malpractice Claims.

Wojcieszak D, Saxton JW, Finkelstein MM. Bloomington, IN: AuthorHouse; 2010. ISBN: 9781438969732.

ORGANIZATIONAL POLICY/GUIDELINES

Disclosure of medical errors involving gametes and embryos.

Ethics Committee of the American Society for Reproductive Medicine. Fertil Steril. 2011;96:1312-1314.

REVIEW

Does full disclosure of medical errors affect malpractice liability? The jury is still out.

Kachalia A, Shojania KG, Hofer TP, Piotrowski M, Saint S. Jt Comm J Qual Saf. 2003;29:503-511.

COMMENTARY

In Conversation with…Thomas H. Gallagher, MD

AHRQ WebM&M [serial online]. January 2009.

STUDY

The many faces of error disclosure: a common set of elements and a definition.

Fein SP, Hilborne LH, Spiritus EM, et al. J Gen Intern Med. 2007;22:755-761.

NEWSPAPER/MAGAZINE ARTICLE

Fixing America's hospitals.

Newsweek. October 16, 2006:44-68, 72.

STUDY

Liability claims and costs before and after implementation of a medical error disclosure program.

Kachalia A, Kaufman SR, Boothman R, et al. Ann Intern Med. 2010;153:213-221.

COMMENTARY

Dealing honestly with an honest mistake.

Liang NL, Herring ME, Bush RL. J Vasc Surg. 2010;51:494-495.

NEWSPAPER/MAGAZINE ARTICLE

Massachusetts hospitals launch patient apology program.

Gallegos A. American Medical News. May 21, 2012.

COMMENTARY classic

Disclosure of medical injury to patients: an improbable risk management strategy.

Studdert DM, Mello MM, Gawande AA, Brennan TA, Wang YC. Health Aff (Millwood). 2007;26:215-226.

COMMENTARY

Apology for errors: whose responsibility?

Leape LL. Front Health Serv Manage. 2012;28:3-12.

COMMENTARY classic

Guilty, afraid, and alone — struggling with medical error.

Delbanco T, Bell SK. N Engl J Med. 2007;357:1682-1683.

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