AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (165)

•Diagnostic Errors (216)

•Identification Errors (107)

•Discontinuities, Gaps, and Hand-Off Problems (461)

•Fatigue and Sleep Deprivation (103)

•Medication Safety (1172)

•Medical Complications (447)

•Nonsurgical Procedural Complications (109)

•Surgical Complications (416)

•Transfusion Complications (16)

•Psychological and Social Complications (131)

Origin/Sponsor

•Africa (5)

•Asia (46)

•Australia and New Zealand (94)

•Central and South America (9)

•Europe (414)

•North America (3137)

Resource Types

•Clinical Guideline (9)

•Journal Article (2798)

•Legislation/Regulation (64)

•Meeting/Conference (22)

•Newsletter/Journal (13)

•Newspaper/Magazine Article (310)

•Press Release/Announcement (29)

•Special or Theme Issue (61)

•Tools/Toolkit (56)

•Web Resource (111)

•Grant (7)

Error Types

•Epidemiology of Errors and Adverse Events (912)

•Active Errors (642)

•Latent Errors (246)

•Near Miss (73)

Approach to Improving Safety

•Quality Improvement Strategies (895)

•Legal and Policy Approaches (299)

•Error Reporting and Analysis (1060)

•Communication Improvement (972)

•Human Factors Engineering (496)

•Teamwork (321)

•Specialization of Care (277)

•Logistical Approaches (297)

•Culture of Safety (452)

•Technologic Approaches (624)

•Education and Training (724)

Clinical Areas

•Allied Health Services (10)

Target Audience
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Health Care Providers

•Allied Health Professionals (6)

•Clinical Technologists (39)

Setting of Care

•Psychiatric Facilities (18)

•Residential Facilities (63)

•Ambulatory Care (409)

•Outpatient Surgery (41)

•Patient Transport (28)

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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.

COMMENTARY

Reducing methicillin-resistant Staphylococcus aureus (MRSA) infections.

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

NEWSPAPER/MAGAZINE ARTICLE

Administering a saline flush "site unseen" can lead to a wrong route error.

ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.

COMMENTARY

Infusing fun into quality and safety initiatives.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Rounding to influence.

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

AUDIOVISUAL

How a simple checklist can dramatically reduce medical errors.

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

STUDY

Determining a patient's comfort in inquiring about healthcare providers' hand-washing behavior.

Clare CA, Afzal O, Knapp K, Viola D. J Patient Saf. 2013;9:68-74.

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.

STUDY

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.

COMMENTARY classic

Balancing "no blame" with accountability in patient safety.

Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.

MULTI-USE WEBSITE

Health Care–Associated Infections (HAI) Portal.

The Joint Commission.

STUDY

A multidisciplinary approach to reduce central line–associated bloodstream infections.

McMullan C, Propper G, Schuhmacher C, et al. Jt Comm J Qual Patient Saf. 2013;39:61-69.

STUDY

Supratherapeutic dosing of acetaminophen among hospitalized patients.

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

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

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.

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