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 (18)

•Identification Errors (15)

•Discontinuities, Gaps, and Hand-Off Problems (51)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (139)

•Medical Complications (102)

•Nonsurgical Procedural Complications (22)

•Surgical Complications (86)

•Transfusion Complications (2)

•Psychological and Social Complications (40)

Origin/Sponsor

•Asia (7)

•Australia and New Zealand (17)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (611)

•Legislation/Regulation (10)

•Meeting/Conference (16)

•Newspaper/Magazine Article (94)

•Press Release/Announcement (4)

•Special or Theme Issue (32)

•Tools/Toolkit (17)

•Web Resource (29)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (91)

•Active Errors (61)

•Latent Errors (68)

•Near Miss (14)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (52)

•Red Rules (2)

•Institutional Patient Safety Plan (24)

•Just Culture (24)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (556)

•Health Care Executives and Administrators (831)

•Non-Health Care Professionals (432)

•Patients (59)

Setting of Care

•Hospitals (570)

•Psychiatric Facilities (4)

•Residential Facilities (25)

•Ambulatory Care (53)

•Outpatient Surgery (5)

•Patient Transport (6)

1 - 20 of 954

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COMMENTARY

Do Not Disturb!

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

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.

STUDY

Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad for Optimal Patient Safety (TOPS) project.

Auerbach AD, Sehgal NL, Blegen MA, et al. BMJ Qual Saf. 2012;22:118-126.

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.

STUDY

Communication practices on 4 Harvard surgical services: a surgical safety collaborative.

ElBardissi AW, Regenbogen SE, Greenberg CC, et al. Ann Surg. 2009;250:861-865.

NEWSPAPER/MAGAZINE ARTICLE

Get me out alive.

Feldman R. The Washington Post. May 2, 2006:HE01.

STUDY

A systems approach to morbidity and mortality conference.

Szostek JH, Wieland ML, Loertscher LL, et al. Am J Med. 2010;123:663-668.

STUDY

Teaching but not learning: how medical residency programs handle errors.

Hoff TJ, Pohl H, Bartfield J. J Org Behav. 2006;27:869-896.

STUDY

Housestaff and medical student attitudes toward medical errors and adverse events.

Vohra PD, Johnson JK, Daugherty CK, Wen M, Barach P. Jt Comm J Qual Patient Saf. 2007;33:493-501.

BOOK/REPORT

Charting the Course: Launching Patient-Centric Healthcare.

Nance JJ, Bartholomew KM. Boseman, MT: Second River Healthcare Press; 2012. ISBN: 9781936406128.

PRESS RELEASE/ANNOUNCEMENT

AHA-NPSF Comprehensive Patient Safety Leadership Fellowship.

American Hospital Association, National Patient Safety Foundation.

COMMENTARY

A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies.

Singh R, Naughton B, Taylor JS, et al. Med Educ. 2005;39:1195-1204.

STUDY

Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project.

Blegen MA, Sehgal NL, Alldredge BK, Gearhart S, Auerbach AD, Wachter RM. Qual Saf Health Care. 2010;19:346-350.

STUDY

Patient safety attitudes of paediatric trainee physicians.

Parry G, Horowitz L, Goldmann D. Qual Saf Health Care. 2009;18:462-466.

REVIEW

Reducing hospital errors: interventions that build safety culture.

Singer SJ, Vogus TJ. Annu Rev Public Health. 2013;34:373-396.

STUDY

Patient safety climate among orthopaedic surgery residents.

Kadzielski J, McCormick F, Zurakowski D, Herndon JH. J Bone Joint Surg Am. 2011;93:e621-e626.

SPECIAL OR THEME ISSUE

Patient Safety.

Matlow A, Laxer RM, eds. Pediatr Clin North Am. 2006;53:1053-1267.

STUDY

Error, stress, and teamwork in medicine and aviation: cross sectional surveys.

Sexton JB, Thomas EJ, Helmreich RL. BMJ. 2000;320:745-749.

STUDY

Eradicating medical student mistreatment: a longitudinal study of one institution's efforts.

Fried JM, Vermillion M, Parker NH, Uijtdehaage S. Acad Med. 2012;87:1191-1198.

STUDY

A resident-led institutional patient safety and quality improvement process.

Stueven J, Sklar DP, Kaloostian P, et al. Am J Med Qual. 2012;27:369-376.

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