AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (233)

•Diagnostic Errors (254)

•Identification Errors (146)

•Discontinuities, Gaps, and Hand-Off Problems (595)

•Fatigue and Sleep Deprivation (124)

•Medication Safety (1466)

•Medical Complications (664)

•Nonsurgical Procedural Complications (127)

•Surgical Complications (527)

•Transfusion Complications (32)

•Psychological and Social Complications (192)

Origin/Sponsor

•Africa (6)

•Asia (72)

•Australia and New Zealand (132)

•Central and South America (10)

•Europe (578)

•North America (4349)

Resource Types

•Clinical Guideline (9)

•Journal Article (3786)

•Legislation/Regulation (71)

•Meeting/Conference (33)

•Newsletter/Journal (14)

•Newspaper/Magazine Article (552)

•Press Release/Announcement (34)

•Special or Theme Issue (71)

•Tools/Toolkit (78)

•Web Resource (135)

•Grant (9)

Error Types

•Epidemiology of Errors and Adverse Events (1237)

•Active Errors (745)

•Latent Errors (326)

•Near Miss (90)

Approach to Improving Safety

•Quality Improvement Strategies (1270)

•Legal and Policy Approaches (513)

•Error Reporting and Analysis (1673)

•Communication Improvement (1187)

•Human Factors Engineering (640)

•Teamwork (416)

•Specialization of Care (354)

•Logistical Approaches (390)

•Culture of Safety (702)

•Technologic Approaches (872)

•Education and Training (965)

Clinical Areas

•Allied Health Services (13)

Target Audience

•Health Care Providers (3719)

•Health Care Executives and Administrators (4132)

•Non-Health Care Professionals (1907)

•Patients (433)

Setting of Care

•Hospitals (3587)

•Psychiatric Facilities (21)

•Residential Facilities (84)

•Ambulatory Care (493)

•Outpatient Surgery (51)

•Patient Transport (32)

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MULTI-USE WEBSITE

On the CUSP: Stop HAI.

Health Research & Educational Trust, MHA Keystone Center.

MEASUREMENT TOOL/INDICATOR

Tubing Misconnections Self Assessment for Healthcare Facilities.

Horsham, PA: Institute for Safe Medication Practices, Deerfield, IL: Baxter Healthcare; 2012.

BOOK/REPORT

Preventing Central Line–Associated Bloodstream Infections: a Global Challenge, a Global Perspective.

The Joint Commission. Oakbrook Terrace, IL: Joint Commission Resources; May 2012.

PRESS RELEASE/ANNOUNCEMENT

New 2012 National Patient Safety Goal - catheter-associated urinary tract infection (CAUTI).

Oakbrook Terrace, IL: Joint Commission; May 17, 2011.

AWARD RECIPIENT

Achievements in eliminating healthcare-associated infections awards.

Washington, DC: US Health and Human Services and Critical Care Societies Collaborative. December 7, 2010.

STUDY

Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST).

Heddle NM, Fung M, Hervig T, et al; BEST Collaborative. Transfusion. 2012;52:1687-1695.

STUDY

Potential unintended consequences due to Medicare's "No Pay for Errors Rule"? A randomized controlled trial of an educational intervention with internal medicine residents.

Mookherjee S, Vidyarthi AR, Ranji SR, Maselli J, Wachter RM, Baron RB. J Gen Intern Med. 2010;25:1097-1101.

COMMENTARY

Reducing methicillin-resistant Staphylococcus aureus (MRSA) infections.

Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:726-731.

BOOK/REPORT

Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project.

Health Research and Educational Trust. Chicago, IL: American Hospital Association; 2010.

STUDY

Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase.

Benning A, Dixon-Woods M, Nwulu U, et al. BMJ. 2011;342:d199.

COMMENTARY

Infusing fun into quality and safety initiatives.

Foulk KC, Tocydlowski P, Snow TM, et al. Nursing. 2012;42:14-16.

STUDY

Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System.

Metersky ML, Hunt DR, Kliman R, et al. Med Care. 2011;49:504-510.

AUDIOVISUAL

How a simple checklist can dramatically reduce medical errors.

Pronovost PJ. On Call. IHI Open School for Health Professionals. November 3, 2008.

STUDY

Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals.

Feigenbaum P, Neuwirth E, Trowbridge L, et al. Med Care. 2012;50:599-605.

NEWSPAPER/MAGAZINE ARTICLE

Events associated with the prescribing, dispensing, and administering of medication loading doses.

Carson SL, Gaunt MJ. PA-PSRS Patient Saf Advis. 2012;9:82-88.

STUDY

Monitoring and reducing central line-associated bloodstream infections: a national survey of state hospital associations.

Murphy DJ, Needham DM, Goeschel C, Fan E, Cosgrove SE, Pronovost PJ. Am J Med Qual. 2010;25:255-260.

STUDY

Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series.

Kirkland KB, Homa KA, Lasky RA, Ptak JA, Taylor EA, Splaine ME. BMJ Qual Saf. 2012;21:1019-1026.

STUDY

Utilizing improvement science methods to improve physician compliance with proper hand hygiene.

White CM, Statile AM, Conway PH, et al. Pediatrics. 2012;129:e1042-e1050.

NEWSPAPER/MAGAZINE ARTICLE

Rounding to influence.

Reinertsen JL, Johnson KM. Healthc Exec. Sept/Oct 2010;25:72-75.

STUDY

Supratherapeutic dosing of acetaminophen among hospitalized patients.

Zhou L, Maviglia SM, Mahoney LM, et al. Arch Intern Med. 2012;172:1721-1728.

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