AHRQ Patient Safety Network

PATIENT SAFETY PRIMERS
Safety Culture

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Safety Culture: High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work... Read Full Glossary Entry >

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Safety Target

•Device-related Complications (30)

•Diagnostic Errors (20)

•Identification Errors (14)

•Discontinuities, Gaps, and Hand-Off Problems (43)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (137)

•Medical Complications (103)

•Nonsurgical Procedural Complications (22)

•Surgical Complications (84)

•Transfusion Complications (2)

•Psychological and Social Complications (41)

Origin/Sponsor

•Asia (7)

•Australia and New Zealand (16)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (607)

•Legislation/Regulation (13)

•Meeting/Conference (16)

•Newspaper/Magazine Article (96)

•Press Release/Announcement (4)

•Special or Theme Issue (32)

•Tools/Toolkit (17)

•Web Resource (26)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (89)

•Active Errors (66)

•Latent Errors (79)

•Near Miss (15)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (54)

•Red Rules (2)

•Institutional Patient Safety Plan (24)

•Just Culture (27)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (543)

•Health Care Executives and Administrators (829)

•Non-Health Care Professionals (453)

•Patients (58)

Setting of Care

•Hospitals (560)

•Psychiatric Facilities (5)

•Residential Facilities (25)

•Ambulatory Care (51)

•Outpatient Surgery (5)

•Patient Transport (6)

1 - 20 of 953

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COMMENTARY classic

Structural and organizational issues in patient safety: a comparison of health care to other high-hazard industries.

Gaba DM. Calif Manage Rev. 2000;43:1-20.

COMMENTARY

Minnesota Hospital Association Statewide Project: SAFE from FALLS.

Apold J, Quigley PA. J Nurs Care Qual. 2012;27:299-306.

COMMENTARY classic

Organizational culture as a source of high reliability.

Weick KE. Calif Manage Rev. 1987;29:112-127.

NEWSPAPER/MAGAZINE ARTICLE

The silent treatment: 'just be quiet about it'.

Smerd J. Workforce Management. November 19, 2007;1, 16-20.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

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

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.

STUDY

Organizational culture, critical success factors, and the reduction of hospital errors.

Stock GN, McFadden KL, Gowen III, CR. Int J Prod Econ. 2007;106:368–392.

NEWSPAPER/MAGAZINE ARTICLE

Plan aims to cut hospital deaths.

Appleby J. USA Today. June 6, 2005.

COMMENTARY

The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives.

Conway WA, Hawkins S, Jordan J, Voutt-Goos MJ. Jt Comm J Qual Patient Saf. 2012;38:318-327.

AUDIOVISUAL

Eye to eye: Donald Berwick.

"Eye to Eye with Katie Couric." CBS News Video. February 6, 2007.

MULTI-USE WEBSITE

MHA Keystone Center for Patient Safety and Quality.

Michigan Health and Hospital Association.

NEWSPAPER/MAGAZINE ARTICLE

A long way to go.

DerGurahian J. Mod Healthc. December 7, 2009.

NEWSPAPER/MAGAZINE ARTICLE

Team-based care.

Weinstock M. Hosp Health Netw. March 2010;84:6p following 28,2.

BOOK/REPORT

Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care.

Roundtable on Joy and Meaning in Work and Workforce Safety, The Lucian Leape Institute. Boston, MA: National Patient Safety Foundation; 2013.

COMMENTARY

Do Not Disturb!

Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.

NEWSPAPER/MAGAZINE ARTICLE

Standards, audits, and saying I'm sorry: an engineer's family proposes solutions.

Wojcieszak D. Patient Safety Qual Healthc. May/June 2005;2:6, 8-9.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2012.

Oakbrook Terrace, IL: The Joint Commission; September 2012.

NEWSPAPER/MAGAZINE ARTICLE

That’s the way we do things around here!

ISMP Medication Safety Alert! Acute Care Edition. February 24, 2011;16:1-2.

NEWSPAPER/MAGAZINE ARTICLE

Raising the index of suspicion: red flags that represent credible threats to patient safety.

ISMP Medication Safety Alert! Acute Care Edition. July 26, 2012;17:1-3.

STUDY

Trainees' perceptions of patient safety practices: recounting failures of supervision.

Ross PT, McMyler ET, Anderson SG, et al. Jt Comm J Qual Patient Saf. 2011;37:88-95.

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