AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (65)

•Diagnostic Errors (117)

•Identification Errors (50)

•Discontinuities, Gaps, and Hand-Off Problems (263)

•Fatigue and Sleep Deprivation (74)

•Medication Safety (997)

•Medical Complications (142)

•Nonsurgical Procedural Complications (37)

•Surgical Complications (231)

•Transfusion Complications (6)

•Psychological and Social Complications (73)

Origin/Sponsor

•Asia (11)

•Australia and New Zealand (23)

•Central and South America (2)

•Europe (94)

•North America (1969)

Resource Types

•Audiovisual (23)

•Award (8)

•Book/Report (71)

•Clinical Guideline (7)

•Journal Article (1557)

•Legislation/Regulation (38)

•Meeting/Conference (13)

•Newsletter/Journal (7)

•Newspaper/Magazine Article (260)

•Press Release/Announcement (19)

•Special or Theme Issue (33)

•Tools/Toolkit (41)

•Web Resource (41)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (404)

•Active Errors (258)

•Latent Errors (99)

•Near Miss (35)

Approach to Improving Safety

•Quality Improvement Strategies (473)

•Legal and Policy Approaches (170)

•Error Reporting and Analysis (502)

•Communication Improvement (538)

•Human Factors Engineering (227)

•Teamwork (137)

•Specialization of Care (150)

•Logistical Approaches (197)

•Culture of Safety (206)

•Technologic Approaches (423)

•Education and Training (407)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (1972)

•Health Care Executives and Administrators (1379)

•Non-Health Care Professionals (579)

•Patients (143)

Setting of Care

•Hospitals (1118)

•Psychiatric Facilities (8)

•Residential Facilities (34)

•Ambulatory Care (353)

•Outpatient Surgery (21)

•Patient Transport (6)

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NEWSPAPER/MAGAZINE ARTICLE

Practitioners agree on medication reconciliation value, but frustration and difficulties abound.

ISMP Medication Safety Alert! Acute Care Edition. July 13, 2006;11:1-2.

NEWSPAPER/MAGAZINE ARTICLE

The consumer: and now, a warning about labels.

Franklin D. New York Times. October 25, 2005:F1.

NEWSPAPER/MAGAZINE ARTICLE

Accuracy at every step: the challenge of medication reconciliation.

Institute for Healthcare Improvement Web site. March 20, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Building a case for medication reconciliation.

Nurse Advise-ERR. April 2006;4:1-3.

NEWSLETTER/JOURNAL

ISMP Medication Safety Alert® Acute Care Edition.

Institute for Safe Medication Practices. 200 Lakeside Drive, Suite 200; Horsham, PA 19044.

COMMENTARY

Medication reconciliation physician order form.

Lacy JL, Wilkinson ST. Hosp Pharm. 2006;41:1117-1120.

STUDY

A steep increase in domestic fatal medication errors with use of alcohol and/or street drugs.

Phillips DP, Barker GEC, Eguchi MM. Arch Intern Med. 2008;168:1561-1566.

COMMENTARY

The (slowly) vanishing prescription pad.

Steinbrook R. N Engl J Med. 2008;359:115-117.

STUDY

Medication dosing errors for patients with renal insufficiency in ambulatory care.

Yap C, Dunham D, Thompson J, Baker D. Jt Comm J Qual Patient Saf. 2005;31:514-521.

AUDIOVISUAL PRESENTATION

Medication error death rate up 500 percent.

Spiesel S, Chadwick A. "Day to Day." National Public Radio. August 27, 2008.

COMMENTARY

How the US drug safety system should be changed.

Strom BL. JAMA. 2006;295:2072-2075.

STUDY

Medication safety in the ambulatory chemotherapy setting.

Gandhi TK, Bartel SB, Shulman LN, et al. Cancer. 2005;104:2477-2483.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:556-557.

STUDY

Challenges in posthospital care: nurses as coaches for medication management.

Costa LL, Poe SS, Lee MC. J Nurs Care Qual. 2011;26:243-251.

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

Risk factors for adverse drug events: a 10-year analysis.

Evans RS, Lloyd JF, Stoddard GJ, Nebeker JR, Samore MH. Ann Pharmacother. 2005;39:1161-1168.

STUDY

Relationship of incorrect dosing of fibrinolytic therapy and clinical outcomes.

Mehta RH, Alexander JH, Van de Werf F, et al. JAMA. 2005;293:1746-1750.

TOOLKIT

Checklist/Action Plan for the Management of High-Alert Medications.

Appendix 1G In: Leading a Strategic Planning Effort: Pathways for Medication Safety. Chicago, IL: American Hospital Association; 2002.

TOOLKIT

ISMP and FDA campaign to eliminate use of error-prone abbreviations.

Huntington Valley, PA: Institute for Safe Medication Practices.

FACT SHEET/FAQS

Thirty Safe Practices for Better Health Care.

National Quality Forum. Rockville, MD: Agency for Healthcare Research and Quality; March 2005. AHRQ Publication No. 04-P025.

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