AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (139)

•Diagnostic Errors (154)

•Identification Errors (81)

•Discontinuities, Gaps, and Hand-Off Problems (429)

•Fatigue and Sleep Deprivation (122)

•Medication Safety (1389)

•Medical Complications (346)

•Nonsurgical Procedural Complications (61)

•Surgical Complications (305)

•Transfusion Complications (17)

•Psychological and Social Complications (120)

Origin/Sponsor

•Australia and New Zealand (43)

•Central and South America (3)

•Europe (187)

•North America (3212)

Resource Types

•Audiovisual (50)

•Book/Report (135)

•Clinical Guideline (9)

•Journal Article (2558)

•Legislation/Regulation (49)

•Meeting/Conference (14)

•Newsletter/Journal (6)

•Newspaper/Magazine Article (525)

•Press Release/Announcement (16)

•Special or Theme Issue (32)

•Tools/Toolkit (50)

•Web Resource (58)

Error Types

•Epidemiology of Errors and Adverse Events (752)

•Active Errors (496)

•Latent Errors (211)

•Near Miss (56)

Approach to Improving Safety

•Quality Improvement Strategies (797)

•Legal and Policy Approaches (358)

•Error Reporting and Analysis (926)

•Communication Improvement (795)

•Human Factors Engineering (385)

•Teamwork (207)

•Specialization of Care (250)

•Logistical Approaches (333)

•Culture of Safety (398)

•Technologic Approaches (836)

•Education and Training (638)

Clinical Areas

•Allied Health Services (5)

•Dentistry (1)

•Medicine (2216)

•Nursing (517)

•Pharmacy (536)

Target Audience

•Health Care Providers (2625)

•Health Care Executives and Administrators (2470)

•Non-Health Care Professionals (1157)

•Patients (318)

Setting of Care

•Hospitals (2515)

•Psychiatric Facilities (11)

•Residential Facilities (63)

•Ambulatory Care (311)

•Outpatient Surgery (26)

•Patient Transport (9)

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STUDY

classic

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

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2011.

Pedersen CA, Schneider PJ, Scheckelhoff DJ. Am J Health Syst Pharm. 2012;69:768-785.

STUDY

classic

Medication errors and adverse drug events in pediatric inpatients.

Kaushal R, Bates DW, Landrigan C, et al. JAMA. 2001;285:2114-2120.

COMMENTARY

Implementing an electronic medical record with computerized prescriber order entry at a critical access hospital.

Horning R. Am J Health Syst Pharm. 2011;68:2288-2292.

COMMENTARY

Preventing medication errors in hospitals through a systems approach and technological innovation: a prescription for 2010.

Crane J, Crane FG. Hosp Top. Fall 2006;84:3-8.

COMMENTARY

Best-practice protocols: Preventing adverse drug events.

Weir VL. Nurs Manage. 2005;36:24-30.

NEWSPAPER/MAGAZINE ARTICLE

Dose of technology helps Shands at UF avoid drug errors.

Chun D. Gainsville Sun. August 21, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Death by handwriting.

Glabman M. Trustee. October 2005;58:29-32.

STUDY

Intravenous acetaminophen in the United States: iatrogenic dosing errors.

Dart RC, Rumack BH. Pediatrics. 2012;129:349-353.

COMMENTARY

Medication bar coding: to scan or not to scan?

Galvin L, McBeth S, Hasdorff C, Tillson M, Thomas S. Comput Inform Nurs. 2007;25:86-92.

STUDY

Risk of medication errors at hospital discharge and barriers to problem resolution.

Enguidanos SM, Brumley RD. Home Health Care Serv Q. 2005;24:123-135.

NEWSPAPER/MAGAZINE ARTICLE

The 'second victims' of medication errors begin to gain support.

Blum K. Pharm Pract News. November 2011.

STUDY

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network.

Poon EG, Blumenfeld B, Hamann C, et al. J Am Med Inform Assoc. 2006;13:581-592.

NEWSPAPER/MAGAZINE ARTICLE

Patients taking their own medications while in the hospital.

PA-PSRS Patient Saf Advis. June 2012;9:50-57.

STUDY

The effect of hospital electronic health record adoption on nurse-assessed quality of care and patient safety.

Kutney-Lee A, Kelly D. J Nurs Adm. 2011;41:466-472.

STUDY

classic

Errors in drug computations during newborn intensive care.

Perlstein PH, Callison C, White M, Barnes B, Edwards NK. Am J Dis Child. 1979;133:376-379.

BOOK/REPORT

Inpatient Computerized Provider Order Entry: Findings from the AHRQ Health IT Portfolio.

Dixon BE, Zafar A, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for Healthcare Research and Quality; January 2009. AHRQ Publication No. 09-0031-EF.

COMMENTARY

Ordering of continuous renal replacement therapy in a computerized provider order entry system.

Oh SS, Sinclair-Pingel J, Feldott CC, Hargrove FR. Hosp Pharm. 2007;42:255–257.

COMMENTARY

ISMP medication error report analysis.

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

REVIEW

The Broselow tape as an effective medication dosing instrument: a review of the literature.

Meguerdichian MJ, Clapper TC. J Pediatr Nurs. 2012;27:416-420.

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