AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (217)

•Diagnostic Errors (214)

•Identification Errors (120)

•Discontinuities, Gaps, and Hand-Off Problems (366)

•Fatigue and Sleep Deprivation (71)

•Medication Safety (1182)

•Medical Complications (442)

•Nonsurgical Procedural Complications (101)

•Surgical Complications (442)

•Transfusion Complications (21)

•Psychological and Social Complications (83)

Origin/Sponsor

•Australia and New Zealand (150)

•Central and South America (15)

•Europe (612)

•North America (2378)

Resource Types

•Audiovisual (28)

•Book/Report (133)

•Clinical Guideline (4)

•Journal Article (2661)

•Legislation/Regulation (38)

•Meeting/Conference (20)

•Newsletter/Journal (5)

•Newspaper/Magazine Article (206)

•Press Release/Announcement (55)

•Special or Theme Issue (45)

•Tools/Toolkit (33)

•Web Resource (85)

Error Types

•Epidemiology of Errors and Adverse Events (1293)

•Active Errors (784)

•Latent Errors (257)

•Near Miss (96)

Approach to Improving Safety

•Quality Improvement Strategies (809)

•Legal and Policy Approaches (226)

•Error Reporting and Analysis (1068)

•Communication Improvement (763)

•Human Factors Engineering (696)

•Teamwork (271)

•Specialization of Care (244)

•Logistical Approaches (228)

•Culture of Safety (368)

•Technologic Approaches (567)

•Education and Training (736)

Clinical Areas

•Allied Health Services (13)

•Complementary and Alternative Medicine (1)

•Dentistry (4)

•Medicine (2451)

•Nursing (299)

•Pharmacy (395)

Target Audience

•Health Care Providers (2648)

•Health Care Executives and Administrators (2907)

•Non-Health Care Professionals (1128)

•Patients (168)

Setting of Care

•Hospitals (2167)

•Psychiatric Facilities (14)

•Residential Facilities (57)

•Ambulatory Care (289)

•Outpatient Surgery (33)

•Patient Transport (36)

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STUDY

Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children.

Uppal N, Yasseen B, Seto W, Parshuram CS. CMAJ. 2011;183:E246-E248.

STUDY

Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units.

De Giorgi I, Fonzo-Christe C, Cingria L, et al. Int J Qual Health Care. 2010;22:170-178.

STUDY

Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II.

Garrouste-Orgeas M, Timsit JF, Vesin A, et al; OUTCOMEREA Study Group. Am J Respir Crit Care Med. 2010:181:134-142.

STUDY

Variability in the concentrations of intravenous drug infusions prepared in a critical care unit.

Wheeler DW, Degnan BA, Sehmi JS, et al. Intensive Care Med. 2008;34:1441-1447.

PRESS RELEASE/ANNOUNCEMENT

Relenza (zanamivir) inhalation powder.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 9, 2009.

STUDY

Rework and workarounds in nurse medication administration process: implications for work processes and patient safety.

Halbesleben JRB, Savage GT, Wakefield DS, Wakefield BJ. Health Care Manage Rev. 2010;35:124-133.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:282-287.

STUDY

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit.

Stavroudis TA, Shore AD, Morlock L, Hicks RW, Bundy D, Miller MR. J Perinatol. 2010;30:459-468.

STUDY

Errors in administration of parenteral drugs in intensive care units: multinational prospective study.

Valentin A, Capuzzo M, Guidet B, et al; Research Group on Quality Improvement of the European Society of Intensive Care Medicine (ESICM); Sentinel Events Evaluation (SEE) Study Investigators. BMJ. 2009;338:b814.

STUDY

A comparison of voluntarily reported medication errors in intensive care and general care units.

Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.

SPECIAL OR THEME ISSUE

Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit.

Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(suppl 6):S83-S264.

STUDY

Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation.

Merry AF, Webster CS, Hannam J, et al. BMJ. 2011;343:d5543.

REVIEW

An international review of patient safety measures in radiotherapy practice.

Shafiq J, Barton M, Noble D, Lemer C, Donaldson LJ. Radiother Oncol. 2009;92:15-21.

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.

PRESS RELEASE/ANNOUNCEMENT

Morphine sulfate oral solution 100 mg per 5 mL (20 mg/mL): medication use error—reports of accidental overdose.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 10, 2011.

STUDY

Medication administration errors in assisted living: scope, characteristics, and the importance of staff training.

Zimmerman S, Love K, Sloane PD, Cohen LW, Reed D, Carder PC; Center for Excellence in Assisted Living-University of North Carolina Collaborative. J Am Geriatr Soc. 2011;59:1060-1068.

STUDY

Computerized order entry with limited decision support to prevent prescription errors in a PICU.

Kadmon G, Bron-Harlev E, Nahum E, Schiller O, Haski G, Shonfeld T. Pediatrics. 2009;124:945-950.

STUDY

Medication errors reported in a pediatric intensive care unit for oncologic patients.

Belela AS, Peterlini MA, Pedreira ML. Cancer Nurs. 2011;34:393-400.

STUDY

Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration.

Yamamoto L, Kanemori J. Am J Emerg Med. 2010;28:588-592.

STUDY

classic

An intervention to decrease catheter-related bloodstream infections in the ICU.

Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.

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