AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (63)

•Diagnostic Errors (58)

•Identification Errors (31)

•Discontinuities, Gaps, and Hand-Off Problems (152)

•Fatigue and Sleep Deprivation (64)

•Medication Safety (288)

•Medical Complications (116)

•Nonsurgical Procedural Complications (37)

•Surgical Complications (130)

•Transfusion Complications (5)

•Psychological and Social Complications (56)

Origin/Sponsor

•Australia and New Zealand (36)

•Central and South America (4)

•Europe (130)

•North America (967)

Resource Types

•Audiovisual (21)

•Book/Report (68)

•Clinical Guideline (1)

•Journal Article (806)

•Legislation/Regulation (11)

•Meeting/Conference (27)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (111)

•Press Release/Announcement (14)

•Special or Theme Issue (27)

•Tools/Toolkit (24)

•Web Resource (62)

Error Types

•Epidemiology of Errors and Adverse Events (161)

•Active Errors (216)

•Latent Errors (80)

•Near Miss (24)

Approach to Improving Safety
< All

Education and Training

•Students (66)

•Residents and Fellows (214)

•Continuing Education (54)

•Online Education (48)

•Simulators (121)

•Teamwork Training (129)

•Patient Education (128)

Clinical Areas

•Allied Health Services (8)

•Complementary and Alternative Medicine (1)

•Dentistry (3)

•Medicine (766)

•Nursing (159)

•Pharmacy (109)

Target Audience

•Health Care Providers (866)

•Health Care Executives and Administrators (847)

•Non-Health Care Professionals (611)

•Patients (104)

Setting of Care

•Hospitals (746)

•Psychiatric Facilities (2)

•Residential Facilities (19)

•Ambulatory Care (87)

•Outpatient Surgery (7)

•Patient Transport (8)

1 - 20 of 1183

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COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

COMMENTARY

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43;788-792.

NEWSPAPER/MAGAZINE ARTICLE

Anticoagulant safety practices call for pharmacist supervision.

Scott A. Drug Topics (Health-System Edition). November 10, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Epidural-IV route mix-ups: reducing the risk of deadly errors.

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

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:696–698.

BOOK/REPORT

Inpatient Computerized Provider Order Entry: Findings from the AHRQ Health IT Portfolio.

Dixon BE, Zafar A, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for Healthcare Research and Quality; January 2009. AHRQ Publication No. 09-0031-EF.

STUDY

Bar-code verification: reducing but not eliminating medication errors.

Henneman PL, Marquard JL, Fisher DL, et al. J Nurs Adm. 2012;42:562-566.

COMMENTARY

A new frontier in patient safety.

McCannon J, Berwick DM. JAMA. 2011;305:2221-2222.

MULTI-USE WEBSITE

BOOSTing Care Transitions Resource Room.

Project BOOST (Better Outcomes for Older adults through Safe Transitions), Society of Hospital Medicine.

STUDY

The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.

Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. Qual Saf Health Care. 2010;19:430-434.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2013.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:282-287.

BOOK/REPORT

The Patient Safety Initiative at America’s Public Hospitals: The Year One Overview.

Research Brief. Washington, DC: National Association of Public Hospitals and Health Systems; January 2011.

BOOK/REPORT

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.

Toft B. London, England: Department of Health; 2001.

REVIEW

Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges.

Goeschel CA, Wachter RM, Pronovost PJ. Chest. 2010;138:171-178.

COMMENTARY classic

classic

Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.

STUDY

Lack of patient knowledge regarding hospital medications.

Cumbler E, Wald H, Kutner J. J Hosp Med. 2010;5-83-86.

NEWSPAPER/MAGAZINE ARTICLE

10 things your hospital won't tell you.

Kapadia R. Smart Money. October 2006;15:112-114.

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