AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (20)

•Diagnostic Errors (6)

•Identification Errors (9)

•Discontinuities, Gaps, and Hand-Off Problems (18)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (98)

•Medical Complications (17)

•Nonsurgical Procedural Complications (7)

•Surgical Complications (26)

•Psychological and Social Complications (4)

Origin/Sponsor

•Europe (7)

•North America (164)

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Newspaper/Magazine Article

Error Types

•Epidemiology of Errors and Adverse Events (13)

•Active Errors (50)

•Latent Errors (15)

•Near Miss (3)

Approach to Improving Safety

•Quality Improvement Strategies (80)

•Legal and Policy Approaches (24)

•Error Reporting and Analysis (38)

•Communication Improvement (49)

•Human Factors Engineering (58)

•Teamwork (12)

•Specialization of Care (9)

•Logistical Approaches (13)

•Culture of Safety (14)

•Technologic Approaches (40)

•Education and Training (33)

Clinical Areas

•Allied Health Services (1)

•Medicine (102)

•Nursing (37)

•Pharmacy (46)

Target Audience

•Health Care Providers (139)

•Health Care Executives and Administrators (108)

•Non-Health Care Professionals (39)

•Patients (54)

Setting of Care

•Hospitals (109)

•Residential Facilities (1)

•Ambulatory Care (9)

•Outpatient Surgery (3)

•Patient Transport (1)

1 - 20 of 172

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NEWSPAPER/MAGAZINE ARTICLE

Promethazine conundrum: IV can hurt more than IM injection!

ISMP Medication Safety Alert! Acute Care Edition. November 2, 2006;11:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Smart pump custom concentrations without hard "low concentration" alerts.

ISMP Medication Safety Alert! Acute Care Edition. February 23, 2012;17:1,3-4.

NEWSPAPER/MAGAZINE ARTICLE

Administering a saline flush "site unseen" can lead to a wrong route error.

ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Design for reliability: barcoded medication administration.

Hayden AC, Lanoue ET, Still CJ. Patient Saf Qual Healthc. July/August 2011;8:12-20.

NEWSPAPER/MAGAZINE ARTICLE

Nurse is charged in death of patient.

Wahlberg D, Treleven E. Wisconsin State Journal. November 3, 2006:A1.

NEWSPAPER/MAGAZINE ARTICLE

Guidelines for timely medication administration: response to the CMS "30-minute rule."

ISMP Medication Safety Alert! Acute Care Edition. January 13, 2011;16:1-4.

NEWSPAPER/MAGAZINE ARTICLE

Clear liquids may place patients at risk.

PA-PSRS Patient Saf Advis. December 2005;2:29-31.

NEWSPAPER/MAGAZINE ARTICLE

Paralyzed by mistakes: preventing errors with neuromuscular blocking agents.

ISMP Medication Safety Alert! Acute Care Edition. September 22, 2005;10:1-3.

NEWSPAPER/MAGAZINE ARTICLE

IV potassium given epidurally: getting to the "route" of the problem.

ISMP Medication Safety Alert! Acute Care Edition. April 6, 2006;11:1-2.

NEWSPAPER/MAGAZINE ARTICLE

Scanner beep only means the barcode has been scanned.

ISMP Medication Safety Alert! Acute Care Edition. June 30, 2011;16:1-2.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals cutting nurses' long shifts.

Kowalczyk L. Boston Globe. September 17, 2005:A1.

NEWSPAPER/MAGAZINE ARTICLE

Going to the hospital? Don't forget to pack a nurse.

Tugend A. New York Times. September 17, 2005;Business/Finance section:9.

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.

NEWSPAPER/MAGAZINE ARTICLE

Loud wake-up call: unlabeled containers lead to patient’s death.

ISMP Medication Safety Alert! Acute Care Edition. December 1, 2004;9:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Scanning out medication errors: Ohio Valley Hospital's automated IV system provides real-time access to patient data.

Carbasho T. Pittsburgh Business Times. April 25, 2005.

NEWSPAPER/MAGAZINE ARTICLE

Error-prone conditions that lead to student nurse-related errors.

ISMP Medication Safety Alert! Acute Care Edition. October 18, 2007;12:1-2.

NEWSPAPER/MAGAZINE ARTICLE

Failure to cap IV tubing and disinfect IV ports place patients at risk for infections.

ISMP Medication Safety Alert! Acute Care Edition. July 26, 2007;12:1-2.

NEWSPAPER/MAGAZINE ARTICLE

Tablet splitting: Do it only if you "half" to, and then do it safely.

ISMP Medication Safety Alert! Acute Care Edition. May 18, 2006;11:1-2.

NEWSPAPER/MAGAZINE ARTICLE classic

Please don't sleep through this wake-up call.

ISMP Medication Safety Alert! Acute Care Edition. May 2, 2001.

NEWSPAPER/MAGAZINE ARTICLE

Exhausted workforce increases the risk of errors.

ISMP Medication Safety Alert. June 2, 2005.

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