AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (190)

•Diagnostic Errors (238)

•Identification Errors (134)

•Discontinuities, Gaps, and Hand-Off Problems (502)

•Fatigue and Sleep Deprivation (88)

•Medication Safety (1613)

•Medical Complications (541)

•Nonsurgical Procedural Complications (115)

•Surgical Complications (505)

•Transfusion Complications (25)

•Psychological and Social Complications (143)

Origin/Sponsor

•Africa (5)

•Asia (58)

•Australia and New Zealand (104)

•Central and South America (10)

•Europe (459)

•North America (3796)

Resource Types

•Clinical Guideline (7)

•Journal Article (3372)

•Legislation/Regulation (56)

•Meeting/Conference (32)

•Newsletter/Journal (13)

•Newspaper/Magazine Article (398)

•Press Release/Announcement (37)

•Special or Theme Issue (62)

•Tools/Toolkit (64)

•Web Resource (115)

•Grant (8)

Error Types

•Epidemiology of Errors and Adverse Events (1490)

•Active Errors (706)

•Latent Errors (254)

•Near Miss (87)

Approach to Improving Safety

•Quality Improvement Strategies (1068)

•Legal and Policy Approaches (371)

•Error Reporting and Analysis (1334)

•Communication Improvement (1045)

•Human Factors Engineering (597)

•Teamwork (337)

•Specialization of Care (295)

•Logistical Approaches (307)

•Culture of Safety (511)

•Technologic Approaches (828)

•Education and Training (806)

Clinical Areas

•Allied Health Services (11)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (3534)

•Health Care Executives and Administrators (3575)

•Non-Health Care Professionals (1575)

•Patients (329)

Setting of Care

•Hospitals (2687)

•Psychiatric Facilities (20)

•Residential Facilities (88)

•Ambulatory Care (536)

•Outpatient Surgery (53)

•Patient Transport (32)

1 - 20 of 4476

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COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:847-853.

STUDY

An in-depth analysis of medication errors in hospitalized patients with HIV.

Snyder AM, Klinker K, Orrick JJ, Janelle J, Winterstein AG. Ann Pharmacother. 2011;45:459-468.

STUDY

Pediatric antidepressant medication errors in a national error reporting database.

Rinke ML, Bundy DG, Shore AD, Colantuoni E, Morlock LL, Miller MR. J Dev Behav Pediatr. 2010;31:129-136.

STUDY

An exploratory study measuring verbal order content and context.

Wakefield DS, Brokel J, Ward MM, Schwichtenberg T, Groath D, Kolb M, Davis JW, Crandall D. Qual Saf Health Care. 2009;18:169-173.

STUDY

Outpatient adverse drug events identified by screening electronic health records.

Gandhi TK, Seger AC, Overhage JM, et al. J Patient Saf. 2010;6;91-96.

STUDY

Listen carefully: the risk of error in spoken medication orders.

Lambert BL, Dickey LW, Fisher WM, et al. Soc Sci Med. 2010;70:1599-1608.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:1062-1065.

STUDY

Adverse drug events in the outpatient setting: an 11-year national analysis.

Bourgeois FT, Shannon MW, Valim C, Mandl KD. Pharmacoepidemiol Drug Saf. 2010;19:901-910.

STUDY

ARV medication errors: experience of a community-based HIV specialty clinic and review of the literature.

Cocohoba J, Dong BJ. Hosp Pharm. 2007;42:720-728.

STUDY

National survey on the effect of oncology drug shortages on cancer care.

McBride A, Holle LM, Westendorf C, et al. Am J Health Syst Pharm. 2013;70:609-617.

REVIEW

Patient safety in dermatology: a review of the literature.

Cao LY, Taylor JS, Vidimos A. Dermatol Online J. 2010;16:3.

NEWSPAPER/MAGAZINE ARTICLE

Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing?

ISMP Medication Safety Alert! Acute Care Edition. November 29, 2012;17:1-3.

STUDY

Consistency between coded poison center data and fatality abstract narratives for therapeutic error deaths in older adults.

Hayes BD, Klein-Schwartz W. Clin Toxicol (Phila). 2010;48:68-71.

STUDY

Utilising improvement science methods to optimise medication reconciliation.

White CM, Schoettker PJ, Conway PH, et al. BMJ Qual Saf. 2011;20:372-380.

STUDY

Priority patient safety issues identified by perioperative nurses.

Steelman VM, Graling PR, Perkhounkova Y. AORN J. 2013;97:402-418.

STUDY

Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.

Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.

STUDY

Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers.

Spiller HA, Borys DJ, Ryan ML, Sawyer TS, Wilson BL. Ann Pharmacother. 2011;45:17-22.

STUDY

Predictive value of alert triggers for identification of developing adverse drug events.

Moore C, Li J, Hung CC, Downs J, Nebeker JR. J Patient Saf. 2009;5:223-228.

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

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.

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