AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (53)

•Diagnostic Errors (60)

•Identification Errors (20)

•Discontinuities, Gaps, and Hand-Off Problems (119)

•Fatigue and Sleep Deprivation (29)

•Medication Safety (284)

•Medical Complications (82)

•Nonsurgical Procedural Complications (19)

•Surgical Complications (71)

•Transfusion Complications (4)

•Psychological and Social Complications (38)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (16)

•Central and South America (2)

•Europe (41)

•North America (865)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (46)

•Active Errors (191)

•Latent Errors (112)

•Near Miss (15)

Approach to Improving Safety

•Quality Improvement Strategies (270)

•Legal and Policy Approaches (162)

•Error Reporting and Analysis (261)

•Communication Improvement (241)

•Human Factors Engineering (186)

•Teamwork (84)

•Specialization of Care (72)

•Logistical Approaches (74)

•Culture of Safety (176)

•Technologic Approaches (238)

•Education and Training (210)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (742)

•Health Care Executives and Administrators (796)

•Non-Health Care Professionals (434)

•Patients (33)

Setting of Care

•Hospitals (594)

•Psychiatric Facilities (1)

•Residential Facilities (9)

•Ambulatory Care (71)

•Outpatient Surgery (3)

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COMMENTARY

Medication bar coding: to scan or not to scan?

Galvin L, McBeth S, Hasdorff C, Tillson M, Thomas S. Comput Inform Nurs. 2007;25:86-92.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

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

COMMENTARY

Enhancing electronic health record usability in pediatric patient care: a scenario-based approach.

Patterson ES, Zhang J, Abbott P, et al. Jt Comm J Qual Patient Saf. 2013;39:129-135.

COMMENTARY

Implementing a bar-code medication administration system.

Weber RJ. Hosp Pharm. 2008;43:1016-1023.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2007;42:675-679.

COMMENTARY

What medications does your patient take? Enhancing medication safety in the outpatient setting.

Institute for Healthcare Improvement. March 14, 2007.

COMMENTARY

Electronic health records and National Patient-Safety Goals.

Sittig DF, Singh H. N Engl J Med. 2012;367:1854-1860.

COMMENTARY

Quest for the ideal: a redesign of the medication use system.

Dang D, Feroli ER, Gill C, et al. J Nurs Care Qual. 2007;22:11-17.

COMMENTARY

Best-practice protocols: Preventing adverse drug events.

Weir VL. Nurs Manage. 2005;36:24-30.

COMMENTARY

Development of the Leapfrog methodology for evaluating hospital implemented inpatient computerized physician order entry systems.

Kilbridge PM, Welebob EM, Classen DC. Qual Saf Health Care. 2006;15:81-84.

COMMENTARY

Improving safety throughout the medication use process in a neonatal intensive care unit.

Asdigha MN. Hosp Pharm. 2006;41:1067-1075.

COMMENTARY

IV medication safety software implementation in a multihospital health system.

Cassano AT. Hosp Pharm. 2006;41:151-156.

COMMENTARY

Citrate Mix-Up

Weber RJ. AHRQ WebM&M [serial online]. May 2006.

COMMENTARY

Safe chemotherapy administration: using failure mode and effects analysis in computerized prescriber order entry.

Kozakiewicz JM, Benis LJ, Fisher SM, Marseglia JB. Am J Health Syst Pharm. 2005;62:1813-1816.

COMMENTARY

Prescribing errors resulting in adverse drug events: how can they be prevented?

Thurmann PA. Expert Opin Drug Saf. 2006;5:489-493.

COMMENTARY

The Role of Bar Coding and Smart Pumps in Safety

Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN AHRQ WebM&M [serial online]. September 2008.

COMMENTARY

In Conversation with…Eric G. Poon, MD, MPH

AHRQ WebM&M [serial online]. September 2008.

COMMENTARY

Using pharmacogenetics to improve drug safety and efficacy.

Haga SB, Burke W. JAMA. 2004;291:2869-2871.

COMMENTARY

Time to sign off on signout.

Stein DM, Stetson PD. Acad Med. 2011;86:804-806.

COMMENTARY

Medication reconciliation physician order form.

Lacy JL, Wilkinson ST. Hosp Pharm. 2006;41:1117-1120.

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