AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (62)

•Diagnostic Errors (15)

•Identification Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (59)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (118)

•Medical Complications (165)

•Nonsurgical Procedural Complications (12)

•Surgical Complications (21)

•Transfusion Complications (3)

•Psychological and Social Complications (5)

Origin/Sponsor

•Australia and New Zealand (35)

•Central and South America (5)

•North America (359)

Resource Types

•Audiovisual (4)

•Book/Report (6)

•Clinical Guideline (2)

•Journal Article (432)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (29)

•Press Release/Announcement (4)

•Special or Theme Issue (4)

•Tools/Toolkit (2)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (156)

•Active Errors (71)

•Latent Errors (23)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (116)

•Legal and Policy Approaches (22)

•Error Reporting and Analysis (117)

•Communication Improvement (79)

•Human Factors Engineering (83)

•Teamwork (63)

•Specialization of Care (144)

•Logistical Approaches (28)

•Culture of Safety (66)

•Technologic Approaches (63)

•Education and Training (70)

Clinical Areas
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Critical Care

Target Audience

•Health Care Providers (334)

•Health Care Executives and Administrators (394)

•Non-Health Care Professionals (129)

•Patients (24)

Setting of Care

•Hospitals (469)

•Psychiatric Facilities (1)

•Residential Facilities (1)

•Ambulatory Care (3)

•Patient Transport (5)

1 - 20 of 492

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NEWSPAPER/MAGAZINE ARTICLE

Perfect is possible.

Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.

STUDY

Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.

Brady PW, Muething S, Kotagal U, et al. Pediatrics. 2013;131:e298-e308.

STUDY

The ability of intensive care units to maintain zero central line–associated bloodstream infections.

Lipitz-Snyderman A, Needham DM, Colantuoni E, et al. Arch Intern Med. 2011;171:856-858.

COMMENTARY

Preventing catheter-related bloodstream infections: thinking outside the checklist.

Perencevich EN, Pittet D. JAMA. 2009;301:1285-1287.

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.

STUDY

Trends in central line–associated bloodstream infections in a trauma-surgical intensive care unit.

Ong A, Dysert K, Herbert C, et al. Arch Surg. 2011;146:302-307.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety: the synergy of technology and behavior.

Yarbrough C, Rypkema S. Patient Safety & Quality Healthcare. January-February 2008;5:32-35.

SPECIAL OR THEME ISSUE

Infection Control in the Intensive Care Unit.

Crit Care Med. 2010;38:S265-S404.

CLINICAL GUIDELINE

Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.

Dellinger RP, Levy MM, Rhodes A, et al; Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Crit Care Med. 2013;41:580-637.

STUDY

Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.

Lin MY, Hota B, Khan YM, et al; CDC Prevention Epicenter Program. JAMA. 2010;304:2035-2041.

STUDY

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.

STUDY

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections.

Sawyer M, Weeks K, Goeschel CA, et al. Crit Care Med. 2010;38(suppl 8):S292-S298.

STUDY

Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units.

Fuchs MA, Sexton DJ, Thornlow DK, Champagne MT. J Nurs Care Qual. 2011;26:101-109.

REVIEW

In-facility delirium programs as a patient safety strategy: a systematic review.

Reston JT, Schoelles KM. Ann Intern Med. 2013;158(5 Pt 2):375-380.

STUDY

Rethinking resident supervision to improve safety: from hierarchical to interprofessional models.

Tamuz M, Giardina TD, Thomas EJ, Menon S, Singh H. J Hosp Med. 2011;6:448-456.

STUDY

classic

Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study.

Pronovost PJ, Goeschel CA, Colantuoni E, et al. BMJ. 2010;340:c309.

STUDY

Differences in outcomes between ICU attending and senior resident physician led medical emergency team responses.

Morris DS, Schweickert W, Holena D, et al. Resuscitation. 2012;83:1434-1437.

STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

STUDY

Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii.

Lin DM, Weeks K, Holzmueller CG, Pronovost PJ, Pham JC. Jt Comm J Qual Patient Saf. 2013;39:51-60.

BOOK/REPORT

MHA Keystone Center for Patient Safety & Quality 2010 Annual Report.

Lansing, MI: Michigan Health & Hospital Association; October 2010.

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