AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (21)

•Diagnostic Errors (37)

•Identification Errors (6)

•Discontinuities, Gaps, and Hand-Off Problems (95)

•Fatigue and Sleep Deprivation (34)

•Medication Safety (388)

•Medical Complications (44)

•Nonsurgical Procedural Complications (8)

•Surgical Complications (35)

•Transfusion Complications (3)

•Psychological and Social Complications (17)

Origin/Sponsor

•Asia (12)

•Australia and New Zealand (12)

•Central and South America (3)

Resource Types

•Clinical Guideline (1)

•Journal Article (544)

•Legislation/Regulation (12)

•Meeting/Conference (3)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (74)

•Press Release/Announcement (12)

•Special or Theme Issue (7)

•Tools/Toolkit (12)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (169)

•Active Errors (98)

•Latent Errors (47)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (155)

•Legal and Policy Approaches (32)

•Error Reporting and Analysis (187)

•Communication Improvement (165)

•Human Factors Engineering (73)

•Teamwork (27)

•Specialization of Care (71)

•Logistical Approaches (72)

•Culture of Safety (43)

•Technologic Approaches (155)

•Education and Training (126)

Clinical Areas

•Allied Health Services (3)

•Medicine (434)

•Nursing (30)

•Pharmacy (230)

Target Audience

•Health Care Providers (659)

•Health Care Executives and Administrators (423)

•Non-Health Care Professionals (160)

•Patients (36)

Setting of Care

•Hospitals (539)

•Residential Facilities (5)

•Ambulatory Care (84)

•Outpatient Surgery (2)

•Patient Transport (1)

1 - 20 of 698

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NEWSPAPER/MAGAZINE ARTICLE

Dose of technology helps Shands at UF avoid drug errors.

Chun D. Gainsville Sun. August 21, 2006.

STUDY

Unintended medication discrepancies at the time of hospital admission.

Cornish PL, Knowles SR, Marchesano R, et al. Arch Intern Med. 2005;165:424-429.

STUDY

Pharmacist medication assessments in a surgical preadmission clinic.

Kwan Y, Fernandes OA, Nagge JJ, et al. Arch Intern Med. 2007;167:1034-1040.

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.

STUDY

Promethazine adverse events after implementation of a medication shortage interchange.

Sheth HS, Verrico MM, Skledar SJ, Towers AL. Ann Pharmacother. 2005;39:255-261.

STUDY

Potential for drug interactions in hospitalized cancer patients.

Riechelmann RP, Moreira F, Smaletz O, Saad ED. Cancer Chemother Pharmacol. 2005;56:286-290.

STUDY

Antiretroviral medication errors in a national medication error database.

Gray J, Hicks RW, Hutchings C. AIDS Patient Care STDS. 2005;19:803-812.

STUDY

Checklists improve experts' diagnostic decisions.

Sibbald M, de Bruin ABH, van Merrienboer JJG. Med Educ. 2013;47:301-308.

STUDY

Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia: [L'observation de mesures simples et efficaces reduit l'incidence de pneumonie associee a la ventilation mecanique].

Baxter AD, Allan J, Bedard J, et al. Can J Anaesth. 2005;52:535-541.

NEWSPAPER/MAGAZINE ARTICLE

"Near injury" alters procedures at Virginia Mason.

Ostrom CM. The Seattle Times. May 21, 2005.

NEWSPAPER/MAGAZINE ARTICLE

Improving the safety of telephone or verbal orders.

PA-PSRS Patient Saf Advis. June 2006;3:1-5.

STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

STUDY

Assessing the National Electronic Injury Surveillance System—Cooperative Adverse Drug Event Surveillance Project—six sites, United States, January 1–June 15, 2004.

Centers for Disease and Control Prevention. MMWR Morb Mortal Wkly Rep. 2005;54:380-383.

STUDY

Failure to weigh patients in hospital: a medication safety risk.

Hilmer SN, Rangiah C, Bajorek BV, Shenfield GM. Intern Med J. 2007;37:647-650.

STUDY

Adverse drug events in hospitalized cardiac patients.

Fanikos J, Cina JL, Baroletti S, Fiumara K, Matta L, Goldhaber SZ. Am J Cardiol. 2007;100:1465-1469.

STUDY

High rates of adverse drug events in a highly computerized hospital.

Nebeker JR, Hoffman JM, Weir CR, Bennett CL, Hurdle JF. Arch Intern Med. 2005;165:1111-1116.

STUDY

Effects of an automatic drug dispensing system on medication adverse event occurrences and cost containment at SAMSO.

Dib JG, Abdulmohsin SA, Farooki MU, et al. Hosp Pharm. 2006;41:1180-1184.

NEWSPAPER/MAGAZINE ARTICLE

JCAHO views medication reconciliation as adverse-event prevention.

Thompson CA. Am J Health Syst Pharm. 2005;62:1528-1532.

NEWSPAPER/MAGAZINE ARTICLE

To protect against drug errors, ask questions.

Brody JE. New York Times. January 2, 2007:F7.

STUDY

Emergency department visits for outpatient adverse drug events: demonstration for a national surveillance system.

Budnitz DS, Pollock DA, Mendelsohn AB, Weidenbach KN, McDonald AK, Annest JL. Ann Emerg Med. 2005;45:197-206.

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