AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (68)

•Diagnostic Errors (112)

•Identification Errors (55)

•Discontinuities, Gaps, and Hand-Off Problems (313)

•Fatigue and Sleep Deprivation (20)

•Medication Safety (946)

•Medical Complications (204)

•Nonsurgical Procedural Complications (46)

•Surgical Complications (170)

•Transfusion Complications (9)

•Psychological and Social Complications (63)

Origin/Sponsor

•Africa (3)

•Asia (20)

•Australia and New Zealand (58)

•Central and South America (8)

•Europe (285)

•North America (1620)

Resource Types

•Clinical Guideline (3)

•Journal Article (1432)

•Legislation/Regulation (26)

•Meeting/Conference (14)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (215)

•Press Release/Announcement (26)

•Special or Theme Issue (31)

•Tools/Toolkit (49)

•Web Resource (64)

•Grant (11)

Error Types

•Epidemiology of Errors and Adverse Events (468)

•Active Errors (495)

•Latent Errors (181)

•Near Miss (38)

Approach to Improving Safety

•Quality Improvement Strategies (482)

•Legal and Policy Approaches (166)

•Error Reporting and Analysis (460)

•Communication Improvement (730)

•Human Factors Engineering (276)

•Teamwork (301)

•Specialization of Care (205)

•Logistical Approaches (132)

•Culture of Safety (283)

•Technologic Approaches (565)

•Education and Training (510)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (1777)

•Health Care Executives and Administrators (1474)

•Non-Health Care Professionals (869)

•Patients (187)

Setting of Care

•Hospitals (1399)

•Psychiatric Facilities (9)

•Residential Facilities (29)

•Ambulatory Care (287)

•Outpatient Surgery (14)

•Patient Transport (12)

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COMMENTARY

XL or Smaller?

Kozer E. AHRQ WebM&M [serial online]. June 2003.

COMMENTARY

The 2-Week Itch.

Cohen MR. AHRQ WebM&M [serial online]. April 2003.

COMMENTARY

Discharge Fumbles.

Forster A. AHRQ WebM&M [serial online]. December 2004.

COMMENTARY

Intubation Mishap.

Weinger MB, Blike GT. AHRQ WebM&M [serial online]. September 2003.

COMMENTARY

Medication Overdose.

Kaushal R. AHRQ WebM&M [serial online]. April 2003.

COMMENTARY

The Dropped Lung.

Heffner JE. AHRQ WebM&M [serial online]. May 2003.

COMMENTARY

X-ray Flip.

Shapiro MJ. AHRQ WebM&M [serial online]. February 2004.

COMMENTARY

The Result Stopped Here.

Astion M. AHRQ WebM&M [serial online]. June 2004.

COMMENTARY

Too Tight Control.

Rubin HR, Fajtova VT. AHRQ WebM&M [serial online]. May 2004.

COMMENTARY

The Missing Suction Tip.

Thomas EJ, Moore FA. AHRQ WebM&M [serial online]. November 2003.

COMMENTARY

Missed Appendicitis.

Adams JG. AHRQ WebM&M [serial online]. June 2003.

COMMENTARY

Caution, Interrupted.

Wears RL. AHRQ WebM&M [serial online]. September 2004.

STUDY

Using CPOE to improve communication, safety, and policy compliance when ordering pediatric chemotherapy.

Crossno CL, Cartwright JA, Hargrove FR. Hosp Pharm. 2007;42:368–373.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

COMMENTARY

40 of K.

Lesar TS. AHRQ WebM&M [serial online]. November 2003.

STUDY

Impact of a standard medication chart on prescribing errors: a before-and-after audit.

Coombes ID, Stowasser DA, Reid C, Mitchell CA. Qual Saf Health Care. 2009;18:478-485.

COMMENTARY

Prescribing errors resulting in adverse drug events: how can they be prevented?

Thurmann PA. Expert Opin Drug Saf. 2006;5:489-493.

COMMENTARY

Inadvertent Castration.

Calland JF. AHRQ WebM&M [serial online]. January 2004.

COMMENTARY

Not a Miscarriage.

Learman LA. AHRQ WebM&M [serial online]. June 2003.

COMMENTARY

Crushing Chest Pain: A Missed Opportunity.

Graber M. AHRQ WebM&M [serial online]. January 2004.

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