AHRQ Patient Safety Network

The Collection > Hospital Medicine

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Safety Target

•Device-related Complications (53)

•Diagnostic Errors (27)

•Identification Errors (26)

•Discontinuities, Gaps, and Hand-Off Problems (225)

•Fatigue and Sleep Deprivation (35)

•Medication Safety (298)

•Medical Complications (226)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (73)

•Transfusion Complications (9)

•Psychological and Social Complications (53)

Origin/Sponsor

•Africa (2)

•Asia (17)

•Australia and New Zealand (41)

•Europe (208)

•North America (1038)

Resource Types

•Audiovisual (18)

•Award (7)

•Book/Report (106)

•Journal Article (922)

•Legislation/Regulation (11)

•Meeting/Conference (7)

•Newspaper/Magazine Article (175)

•Press Release/Announcement (2)

•Special or Theme Issue (12)

•Tools/Toolkit (19)

•Web Resource (28)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (348)

•Active Errors (158)

•Latent Errors (111)

•Near Miss (18)

Approach to Improving Safety

•Quality Improvement Strategies (332)

•Legal and Policy Approaches (160)

•Error Reporting and Analysis (380)

•Communication Improvement (333)

•Human Factors Engineering (133)

•Teamwork (83)

•Specialization of Care (103)

•Logistical Approaches (106)

•Culture of Safety (235)

•Technologic Approaches (202)

•Education and Training (232)

Clinical Areas
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Hospital Medicine

Target Audience

•Health Care Providers (702)

•Health Care Executives and Administrators (1064)

•Non-Health Care Professionals (505)

•Patients (122)

Setting of Care

•Hospitals (1288)

•Psychiatric Facilities (4)

•Residential Facilities (7)

•Ambulatory Care (32)

•Outpatient Surgery (4)

•Patient Transport (2)

1 - 20 of 1308

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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.

COMMENTARY classic

Balancing "no blame" with accountability in patient safety.

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

ORGANIZATIONAL POLICY/GUIDELINES classic

A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals.

Yokoe DS, Mermel LA, Anderson DJ, et al. Infect Control Hosp Epidemiol. 2008;29:901-994.

MULTI-USE WEBSITE

On the CUSP: Stop HAI.

Health Research & Educational Trust, MHA Keystone Center.

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.

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.

NEWSPAPER/MAGAZINE ARTICLE

Perfect is possible.

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

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.

AWARD RECIPIENT

Achievements in eliminating healthcare-associated infections awards.

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

PRESS RELEASE/ANNOUNCEMENT

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

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

COMMENTARY

Learning accountability for patient outcomes.

Pronovost PJ. JAMA. 2010;304:204-205.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

STUDY

Impact of participation in the California Healthcare-Associated Infection Prevention Initiative on adoption and implementation of evidence-based practices for patient safety and health care–associated infection rates in a cohort of acute care general hospitals.

Halpin HA, McMenamin SB, Simon LP, et al. Am J Infect Control. 2013;41:307-311.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

NEWSPAPER/MAGAZINE ARTICLE

Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm.

ISMP Medication Safety Alert! Acute Care Edition. May 30, 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.

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.

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

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.

STUDY

Practically speaking: rethinking hand hygiene improvement programs in health care settings.

Son C, Chuck T, Childers T, et al. Am J Infect Control. 2011;39:716-724.

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