AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (168)

•Diagnostic Errors (154)

•Identification Errors (102)

•Discontinuities, Gaps, and Hand-Off Problems (344)

•Fatigue and Sleep Deprivation (84)

•Medication Safety (944)

•Medical Complications (466)

•Nonsurgical Procedural Complications (88)

•Surgical Complications (387)

•Transfusion Complications (18)

•Psychological and Social Complications (104)

Origin/Sponsor
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United States of America

•United States Federal Government (176)

•State Governments and Agencies (22)

Resource Types

•Audiovisual (37)

•Book/Report (170)

•Clinical Guideline (7)

•Journal Article (2496)

•Legislation/Regulation (41)

•Meeting/Conference (22)

•Newsletter/Journal (6)

•Newspaper/Magazine Article (317)

•Press Release/Announcement (24)

•Special or Theme Issue (45)

•Tools/Toolkit (30)

•Web Resource (65)

Error Types

•Epidemiology of Errors and Adverse Events (1014)

•Active Errors (456)

•Latent Errors (178)

•Near Miss (61)

Approach to Improving Safety

•Quality Improvement Strategies (810)

•Legal and Policy Approaches (314)

•Error Reporting and Analysis (1011)

•Communication Improvement (721)

•Human Factors Engineering (427)

•Teamwork (287)

•Specialization of Care (234)

•Logistical Approaches (273)

•Culture of Safety (678)

•Technologic Approaches (572)

•Education and Training (688)

Clinical Areas

•Allied Health Services (9)

•Dentistry (5)

•Medicine (2211)

•Nursing (357)

•Pharmacy (349)

Target Audience

•Health Care Providers (2236)

•Health Care Executives and Administrators (2815)

•Non-Health Care Professionals (1168)

•Patients (206)

Setting of Care

•Hospitals (2057)

•Psychiatric Facilities (10)

•Residential Facilities (68)

•Ambulatory Care (280)

•Outpatient Surgery (40)

•Patient Transport (23)

1 - 20 of 3289

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STUDY

classic

An intervention to decrease catheter-related bloodstream infections in the ICU.

Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.

STUDY

Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.

Lin MY, Hota B, Khan YM, et al; CDC Prevention Epicenter Program. JAMA. 2010;304:2035-2041.

STUDY

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.

STUDY

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections.

Sawyer M, Weeks K, Goeschel CA, et al. Crit Care Med. 2010;38(suppl 8):S292-S298.

STUDY

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.

STUDY

Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units.

Fuchs MA, Sexton DJ, Thornlow DK, Champagne MT. J Nurs Care Qual. 2011;26:101-109.

STUDY

Trends in central line–associated bloodstream infections in a trauma-surgical intensive care unit.

Ong A, Dysert K, Herbert C, et al. Arch Surg. 2011;146:302-307.

STUDY

Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations.

Angus DC, Shorr AF, White A, Dremsizov TT, Schmitz RJ, Kelley MA, on behalf of the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Crit Care Med. 2006;34:1016-1024.

STUDY

Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans.

Vigorito MC, McNicoll L, Adams L, Sexton B. Jt Comm J Qual Patient Saf. 2011;37:509-514.

STUDY

Toward learning from patient safety reporting systems.

Pronovost PJ, Thompson DA, Holzmueller CG, et al. J Crit Care. 2006;21:305-315.

STUDY

Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii.

Lin DM, Weeks K, Holzmueller CG, Pronovost PJ, Pham JC. Jt Comm J Qual Patient Saf. 2013;39:51-60.

STUDY

A multicenter, phased, cluster-randomized controlled trial to reduce central line–associated bloodstream infections in intensive care units.

Marsteller JA, Sexton JB, Hsu YJ, et al. Crit Care Med. 2012;40:2933-2939.

COMMENTARY

Preventing catheter-related bloodstream infections: thinking outside the checklist.

Perencevich EN, Pittet D. JAMA. 2009;301:1285-1287.

STUDY

The ability of intensive care units to maintain zero central line–associated bloodstream infections.

Lipitz-Snyderman A, Needham DM, Colantuoni E, et al. Arch Intern Med. 2011;171:856-858.

COMMENTARY

What went right: lessons for the intensivist from the crew of US Airways Flight 1549.

Eisen LA, Savel RH. Chest. 2009;136:910-917.

STUDY

A comparison of voluntarily reported medication errors in intensive care and general care units.

Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.

COMMENTARY classic

classic

Reality check for checklists.

Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ. Lancet. 2009;374:444-445.

PRESS RELEASE/ANNOUNCEMENT classic

classic

AHRQ Patient Safety Project Reduces Bloodstream Infections by 40 Percent.

Rockville, MD: Agency for Healthcare Research and Quality; September 10, 2012.

STUDY

Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: business case for quality improvement.

Nowak JE, Brilli RJ, Lake MR, et al. Pediatr Crit Care Med. 2010;11:579-587.

STUDY

Adverse drug event reporting in intensive care units: a survey of current practices.

Kane-Gill SL, Devlin JW. Ann Pharmacother. 2006;40:1267-73.

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