AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (103)

•Diagnostic Errors (31)

•Identification Errors (44)

•Discontinuities, Gaps, and Hand-Off Problems (198)

•Fatigue and Sleep Deprivation (57)

•Medication Safety (1016)

•Medical Complications (207)

•Nonsurgical Procedural Complications (29)

•Surgical Complications (129)

•Transfusion Complications (6)

•Psychological and Social Complications (66)

Origin/Sponsor

•Africa (1)

•Asia (15)

•Australia and New Zealand (18)

•Central and South America (4)

•Europe (88)

•North America (2166)

Resource Types

•Clinical Guideline (1)

•Journal Article (1505)

•Legislation/Regulation (36)

•Meeting/Conference (21)

•Newsletter/Journal (7)

•Newspaper/Magazine Article (380)

•Press Release/Announcement (18)

•Special or Theme Issue (36)

•Tools/Toolkit (32)

•Web Resource (41)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (434)

•Active Errors (271)

•Latent Errors (124)

•Near Miss (36)

Approach to Improving Safety

•Quality Improvement Strategies (654)

•Legal and Policy Approaches (305)

•Error Reporting and Analysis (595)

•Communication Improvement (473)

•Human Factors Engineering (285)

•Teamwork (147)

•Specialization of Care (215)

•Logistical Approaches (179)

•Culture of Safety (394)

•Technologic Approaches (535)

•Education and Training (403)

Clinical Areas

•Allied Health Services (7)

Target Audience

•Health Care Providers (1556)

•Health Care Executives and Administrators (2006)

•Non-Health Care Professionals (938)

•Patients (192)

Setting of Care

•Hospitals (1458)

•Psychiatric Facilities (8)

•Residential Facilities (38)

•Ambulatory Care (181)

•Outpatient Surgery (13)

•Patient Transport (6)

1 - 20 of 2295

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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

Errors associated with medications removed from automated dispensing machines using override functions.

Kester K, Baxter J, Freudenthal K. Hosp Pharm. 2006;41:535-537.

STUDY

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2008.

Pedersen CA, Schneider P, Scheckelhoff DJ. Am J Health Syst Pharm. 2009;66:926-946.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:13-17.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:730-733.

COMMENTARY

Addressing safety concerns about U-500 insulin in a hospital setting.

Samaan KH, Dahlke M, Stover J. Am J Health Syst Pharm. 2011;68:63-68.

STUDY

Effects of an adverse-drug-event alert system on cost and quality outcomes in community hospitals.

Piontek F, Kohli R, Conlon P, Ellis JJ, Jablonski J, Kini N. Am J Health Syst Pharm. 2010;67:613-620.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:618-621.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:445-448.

STUDY

How many hospital pharmacy medication dispensing errors go undetected?

Cina JL, Gandhi TK, Churchill W, et al. Jt Comm J Qual Patient Saf. 2006;32:73-80.

STUDY

A network collaboration implementing technology to improve medication dispensing and administration in critical access hospitals.

Wakefield DS, Ward MM, Loes JL, O'Brien J. J Am Med Inform Assoc. 2010;17:584-587.

COMMENTARY classic

Computerization can create safety hazards: a bar-coding near miss.

McDonald CJ. Ann Intern Med. 2006;144:510-516.

STUDY

Designing decision support for insulin ordering in a computerized provider order entry system.

Wright L, Feldott CC, Hargrove FR. Hosp Pharm. 2007;42:158–161.

STUDY

Severity of medication administration errors detected by a bar-code medication administration system.

Sakowski J, Newman JM, Dozier K. Am J Health Syst Pharm. 2008;65:1661-1666.

STUDY

Assessing the anticipated consequences of computer-based provider order entry at three community hospitals using an open-ended, semi-structured survey instrument.

Sittig DF, Ash JS, Guappone KP, Campbell EM, Dykstra RH. Int J Med Inform. 2008;77:440-447.

STUDY

Impact of a pharmacist on medication reconciliation on patient admission to a Veterans Affairs Medical Center.

Strunk LB, Matson AW, Steinke D. Hosp Pharm. 2008;43:643-649.

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.

STUDY

Effect of bar-code technology on the safety of medication administration.

Poon EG, Keohane CA, Yoon CS, et al. N Engl J Med. 2010;362:1698-1707.

REVIEW

Effect of clinical pharmacists on care in the emergency department: a systematic review.

Cohen V, Jellinek SP, Hatch A, Motov S. Am J Health Syst Pharm. 2009;66:1353-1361.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2007;42:790-792.

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