AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (16)

•Diagnostic Errors (30)

•Identification Errors (7)

•Discontinuities, Gaps, and Hand-Off Problems (31)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (101)

•Medical Complications (51)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (33)

•Transfusion Complications (1)

•Psychological and Social Complications (4)

Origin/Sponsor

•Asia (11)

•Australia and New Zealand (7)

Resource Types

•Journal Article (245)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (25)

•Special or Theme Issue (3)

•Tools/Toolkit (5)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (106)

•Active Errors (64)

•Latent Errors (22)

•Near Miss (5)

Approach to Improving Safety
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Audit and Feedback

Clinical Areas

•Allied Health Services (1)

•Medicine (211)

•Nursing (15)

•Pharmacy (33)

Target Audience

•Health Care Providers (205)

•Health Care Executives and Administrators (258)

•Non-Health Care Professionals (95)

•Patients (11)

Setting of Care

•Hospitals (215)

•Residential Facilities (5)

•Ambulatory Care (30)

•Outpatient Surgery (6)

•Patient Transport (1)

1 - 20 of 294

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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.

STUDY

Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.

Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.

STUDY

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.

STUDY

Temporal trends in rates of patient harm resulting from medical care.

Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. N Engl J Med. 2010;363:2124-2134.

COMMENTARY

The Team Checkup Tool: evaluating QI team activities and giving feedback to senior leaders.

Lubomski LH, Marsteller JA, Hsu YJ, et al. Jt Comm J Qual Patient Saf. 2008;34:619-623.

STUDY

National estimates of adverse events during nonpsychiatric hospitalizations for persons with schizophrenia.

Khaykin E, Ford DE, Pronovost PJ, Dixon L, Daumit GL. Gen Hosp Psychiatry. 2010;32:419-425.

STUDY

An inpatient fall prevention initiative in a tertiary care hospital.

Weinberg J, Proske D, Szerszen A, et al. Jt Comm J Qual Patient Saf. 2011;37:317-325.

MEASUREMENT TOOL/INDICATOR

Medication Safety Self Assessment for Automated Dispensing Cabinets.

Horsham, PA: Institute for Safe Medication Practices; 2009.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.

STUDY

'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured.

Classen DC, Resar R, Griffin F, et al. Health Aff (Millwood). 2011;30:581-589.

STUDY

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.

STUDY

Analysis of staff safety concerns.

Davidson J, Lamontagne G, Burnell L, et al. J Nurs Care Qual. 2013;28:147-152.

TOOLKIT

Making Strides in Safety.

Chicago, IL: American Medical Association.

STUDY

The safety of hospital stroke care.

Holloway RG, Tuttle D, Baird T, Skelton WK. Neurology. 2007;68:550-555.

BOOK/REPORT

National Diabetes Inpatient Audit 2011.

Leeds, UK: Health and Social Care Information Centre; 2012.

COMMENTARY

I-CaRe: a case review tool focused on improving inpatient care.

Huang Lee J, Vidyarthi AR, Sehgal NL, Auerbach AD, Wachter RM. Jt Comm J Qual Patient Saf. 2009;35:115-119.

NEWSPAPER/MAGAZINE ARTICLE

Collaboration focused on priority issues promotes safety.

ISMP Medication Safety Alert! Acute Care Edition. October 10, 2008;13:1-3.

STUDY

Professionalism: a necessary ingredient in a culture of safety.

DuPree E, Anderson R, McEvoy MD, Brodman M. Jt Comm J Qual Patient Saf. 2011;37:447-455.

STUDY

Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant.

Levtzion-Korach O, Frankel A, Alcalai H, et al. Jt Comm J Qual Patient Saf. 2010;36:402-410.

STUDY

Implementing peer evaluation of handoffs: associations with experience and workload.

Arora VM, Greenstein EA, Woodruff JN, Staisiunas PG, Farnan JM. J Hosp Med. 2013;8:132-136.

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