AHRQ Patient Safety Network

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The Collection

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Safety Target

•Device-related Complications (45)

•Diagnostic Errors (53)

•Identification Errors (52)

•Discontinuities, Gaps, and Hand-Off Problems (161)

•Fatigue and Sleep Deprivation (27)

•Medication Safety (452)

•Medical Complications (138)

•Nonsurgical Procedural Complications (24)

•Surgical Complications (156)

•Transfusion Complications (12)

•Psychological and Social Complications (43)

Origin/Sponsor

•Asia (9)

•Australia and New Zealand (16)

•Europe (75)

•North America (1110)

Resource Types
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Study

Error Types

•Epidemiology of Errors and Adverse Events (477)

•Active Errors (213)

•Latent Errors (105)

•Near Miss (34)

Approach to Improving Safety

•Quality Improvement Strategies (242)

•Legal and Policy Approaches (46)

•Error Reporting and Analysis (359)

•Communication Improvement (240)

•Human Factors Engineering (134)

•Teamwork (92)

•Specialization of Care (90)

•Logistical Approaches (110)

•Culture of Safety (115)

•Technologic Approaches (404)

•Education and Training (200)

Clinical Areas

•Allied Health Services (3)

•Medicine (904)

•Nursing (149)

•Pharmacy (150)

Target Audience

•Health Care Providers (831)

•Health Care Executives and Administrators (1131)

•Non-Health Care Professionals (609)

•Patients (8)

Setting of Care

•Hospitals (847)

•Psychiatric Facilities (5)

•Residential Facilities (26)

•Ambulatory Care (131)

•Outpatient Surgery (10)

•Patient Transport (8)

1 - 20 of 1206

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STUDY

Medication-error alerts for warfarin orders detected by a bar-code-assisted medication administration system.

Fitzhenry F, Doran J, Lobo B, et al. Am J Health Syst Pharm. 2011;68:434-441.

STUDY

Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study.

Morriss FH Jr, Abramowitz PW, Nelson SP, et al. J Pediatr. 2009;197:678-685.

STUDY

The use of patient pictures and verification screens to reduce computerized provider order entry errors.

Hyman D, Laire M, Redmond D, Kaplan DW. Pediatrics. 2012;130:e211-e219.

STUDY

A case of mistaken identity: staff input on patient ID errors.

Ortiz J, Amatucci C. Nurs Manage. April 2009;4:37-41.

STUDY

Nurse interruptions pre- and post-implementation of a point-of-care medication administration system.

Stamp KD, Willis DG. J Nurs Care Qual. 2010;25:231-239.

STUDY

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.

Staggers N, Clark L, Blaz JW, Kapsandoy S. Health Informatics J. 2011;17:209-223.

STUDY

Complexity of medication-related verbal orders.

Wakefield DS, Ward MM, Groath D, et al. Am J Med Qual. 2008;23:7-17.

STUDY

Evaluation of causes and frequency of medication errors during information technology downtime.

Hanuscak TL, Szeinbach SL, Seoane-Vazquez E, Reichert BJ, McCluskey CF. Am J Health Syst Pharm. 2009;66:1119-1124.

STUDY

Bar-code technology for medication administration: medication errors and nurse satisfaction.

Fowler SB, Sohler P, Zarillo DF. MedSurg Nursing. 2009;18:103-110.

STUDY

Paper- and computer-based workarounds to electronic health record use at three benchmark institutions.

Flanagan ME, Saleem JJ, Millitello LG, Russ AL, Doebbeling BN. J Am Med Inform Assoc. 2013 Mar 14; [Epub ahead of print].

STUDY

Matching identifiers in electronic health records: implications for duplicate records and patient safety.

McCoy AB, Wright A, Kahn MG, Shapiro JS, Bernstam EV, Sittig DF. BMJ Qual Saf. 2013;22:219-224.

STUDY

Bar code medication administration technology: characterization of high-alert medication triggers and clinician workarounds.

Miller DF, Fortier CR, Garrison KL. Ann Pharmacother. 2011;45:162-168.

STUDY

Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information.

Keenan G, Yakel E, Dunn Lopez K, Tschannen D, Ford YB. J Am Med Inform Assoc. 2013;20:245-251.

STUDY

Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.

Adelman JS, Kalkut GE, Schechter CB, et al. J Am Med Inform Assoc. 2013;20:305-310.

STUDY

Minimizing electronic health record patient–note mismatches.

Wilcox AB, Chen YH, Hripcsak G. J Am Med Inform Assoc. 2011;18:511-514.

STUDY

Effects of CPOE on provider cognitive workload: a randomized crossover trial.

Avansino J, Leu MG. Pediatrics. 2012;130:e547-e552.

STUDY

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.

STUDY

A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume endoscopy center.

Francis DL, Prabhakar S, Sanderson SO. Am J Gastroenterol. 2009;104:972-975.

STUDY

Risk of adverse drug events in neonates treated with opioids and the effect of a bar-code–assisted medication administration system.

Morriss FH, Jr, Abramowitz PW, Nelson SP, Milavetz G, Michael SL, Gordon SN. Am J Health Syst Pharm. 2011;68:57-62.

STUDY

An intervention to decrease patient identification band errors in a children's hospital.

Hain PD, Joers B, Rush M, et al. Qual Saf Health Care. 2010;19:244-247.

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