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 (15)

•Identification Errors (17)

•Discontinuities, Gaps, and Hand-Off Problems (52)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (155)

•Medical Complications (105)

•Nonsurgical Procedural Complications (21)

•Surgical Complications (107)

•Transfusion Complications (3)

•Psychological and Social Complications (40)

Origin/Sponsor

•Asia (12)

•Australia and New Zealand (13)

•Central and South America (3)

Resource Types

•Clinical Guideline (1)

•Journal Article (607)

•Legislation/Regulation (9)

•Meeting/Conference (13)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (92)

•Press Release/Announcement (2)

•Special or Theme Issue (31)

•Tools/Toolkit (14)

•Web Resource (21)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (89)

•Active Errors (65)

•Latent Errors (64)

•Near Miss (17)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (34)

•Red Rules (2)

•Institutional Patient Safety Plan (19)

•Just Culture (22)

Clinical Areas

•Allied Health Services (5)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (541)

•Health Care Executives and Administrators (785)

•Non-Health Care Professionals (396)

•Patients (55)

Setting of Care

•Hospitals (520)

•Psychiatric Facilities (4)

•Residential Facilities (25)

•Ambulatory Care (56)

•Outpatient Surgery (5)

•Patient Transport (8)

1 - 20 of 904

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STUDY

Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.

Espin S, Levinson W, Regehr G, Baker GR, Lingard L. Surgery. 2006;139:6-14.

COMMENTARY

Creating a culture of safety by using checklists.

Huang L, Kim R, Berry W. AORN J. 2013;97:365-368.

MULTI-USE WEBSITE

Patient Safety First.

AORN, Inc., 2170 South Parker Rd, Suite 300, Denver, CO 80231-5711.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Report on Quality and Safety 2008.

Oakbrook Terrace, IL: The Joint Commission; November 2008.

STUDY

Bridging the communication gap in the operating room with medical team training.

Awad SS, Fagan SP, Bellows C, et al. Am J Surg. 2005;190:770-774.

SPECIAL OR THEME ISSUE

Patient Safety.

Plastic Surg Nurs. 2006;26:111-170.

NEWSPAPER/MAGAZINE ARTICLE

Trends influencing the cost of care and patient safety.

Clark R. Health Manage Tech. July 2006:18, 20-21.

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.

COMMENTARY

Patient safety in the dialysis facility.

Kliger AS. Blood Purif. 2006;24:19-21.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.

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.

REVIEW

Promoting a culture of patient safety: a review of the Florida moratoria data: what we have learned in 6 years and the need for continued patient education.

Clayman MA, Clayman SM, Steele MH, Seagle MB. Ann Plastic Surg. 2007;58:288-291.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

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

COMMENTARY

The normalization of deviance: what are the perioperative risks?

McNamara SA. AORN J. 2011;93:796-801.

STUDY

The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical units.

Thomas EJ, Sexton JB, Neilands TB, Frankel A, Helmreich RL. BMC Health Serv Res. 2005;5:28.

COMMENTARY

Passing the "Yo' Mama" test.

Blair R. Health Manage Tech. June 2006;27:16.

STUDY

Adopting National Quality Forum medication safe practices: progress and barriers to hospital implementation.

Rask K, Culler S, Scott T, et al. J Hosp Med. 2007;2:212-218.

STUDY

Medication safety infrastructure in critical-access hospitals in Florida.

Winterstein AG, Hartzema AG, Johns TE, et al. Am J Health Syst Pharm. 2006;63:442-450.

BOOK/REPORT

Pediatric Patient Safety in the Emergency Department.

Krug SE, ed. Oak Brook, IL: Joint Commission Resources and the American Academy of Pediatrics; 2010. ISBN: 9781599402123.

BOOK/REPORT classic

Safe Practices for Better Healthcare—2010 Update.

National Quality Forum. Washington, DC: National Quality Forum; 2010.

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