AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (20)

•Diagnostic Errors (61)

•Identification Errors (13)

•Discontinuities, Gaps, and Hand-Off Problems (154)

•Fatigue and Sleep Deprivation (26)

•Medication Safety (242)

•Medical Complications (32)

•Nonsurgical Procedural Complications (10)

•Surgical Complications (46)

•Psychological and Social Complications (30)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (8)

•Europe (14)

•North America (529)

Resource Types
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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (27)

•Active Errors (164)

•Latent Errors (135)

•Near Miss (17)

Approach to Improving Safety

•Quality Improvement Strategies (153)

•Legal and Policy Approaches (71)

•Error Reporting and Analysis (150)

•Communication Improvement (250)

•Human Factors Engineering (100)

•Teamwork (41)

•Specialization of Care (47)

•Logistical Approaches (58)

•Culture of Safety (80)

•Technologic Approaches (131)

•Education and Training (150)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (540)

•Health Care Executives and Administrators (401)

•Non-Health Care Professionals (205)

•Patients (23)

Setting of Care

•Hospitals (326)

•Psychiatric Facilities (3)

•Residential Facilities (7)

•Ambulatory Care (72)

•Outpatient Surgery (2)

•Patient Transport (3)

1 - 20 of 618

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COMMENTARY

Medication reconciliation physician order form.

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

COMMENTARY

Improving care transitions: current practice and future opportunities for pharmacists.

American College of Clinical Pharmacy, Hume AL, Kirwin J, et al. Pharmacotherapy. 2012;32:e326-e337.

COMMENTARY

Citrate Mix-Up

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

COMMENTARY

Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge.

Rodehaver C. Jt Comm J Qual Patient Saf. 2005;31:406-413.

COMMENTARY

ISMP medication error report analysis.

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

COMMENTARY

Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010.

Crane J, Crane FG. Hosp Top. Fall 2006;84:3-8.

COMMENTARY

Electronic Err.

Tang PC. AHRQ WebM&M [serial online]. October 2004.

COMMENTARY

Using pharmacogenetics to improve drug safety and efficacy.

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

COMMENTARY

Improving care transitions: optimizing medication reconciliation.

American Pharmacists Association, American Society of Health-System Pharmacists. J Am Pharm Assoc. 2012;52:e43-e52.

COMMENTARY

Appropriate prescribing of medications: an eight-step approach.

Pollock M, Bazaldua OV, Dobbie AE. Am Fam Physician. 2007;75:231-236, 239-240.

COMMENTARY

The (slowly) vanishing prescription pad.

Steinbrook R. N Engl J Med. 2008;359:115-117.

COMMENTARY

Partners in safety: implementing a community-based patient safety advisory council.

Leonhardt KK, Bonin D, Pagel P. Wisc Med J. 2006;105;54-59.

COMMENTARY

Implementation of a specialized pharmacy team to monitor high-risk medications during discharge.

Martin ES III, Overstreet RL, Jackson-Khalil LR, McCollough HL, Meyer TA, Xu Q. Am J Health Syst Pharm. 2013;70:18-21.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:556-557.

COMMENTARY

Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge.

Murphy EM, Oxencis CJ, Klauck JA, Meyer DA, Zimmerman JM. Am J Health Syst Pharm. 2009;66:2126-2131.

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

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

COMMENTARY

Automated electronic reminders to prevent miscommunication among primary medical, surgical and anaesthesia providers: a root cause analysis.

Freundlich RE, Grondin L, Tremper KK, Saran KA, Kheterpal S. BMJ Qual Saf. 2012;21:850-854.

COMMENTARY

Supporting the Patient Safety and Clinical Pharmacy Services Collaborative.

Mitchell JR. Am J Health Syst Pharm. 2012;69:1246-1250.

COMMENTARY

Physical Diagnosis: A Lost Art?

Thompson GR, Verghese A. AHRQ WebM&M [serial online]. August 2006.

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