AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (88)

•Diagnostic Errors (90)

•Identification Errors (44)

•Discontinuities, Gaps, and Hand-Off Problems (206)

•Fatigue and Sleep Deprivation (80)

•Medication Safety (808)

•Medical Complications (137)

•Nonsurgical Procedural Complications (41)

•Surgical Complications (165)

•Transfusion Complications (6)

•Psychological and Social Complications (49)

Origin/Sponsor

•Africa (1)

•Asia (46)

•Australia and New Zealand (47)

•Central and South America (6)

•Europe (476)

•North America (1208)

Resource Types

•Audiovisual (15)

•Award (1)

•Book/Report (65)

•Clinical Guideline (7)

•Journal Article (1461)

•Legislation/Regulation (24)

•Meeting/Conference (4)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (180)

•Press Release/Announcement (21)

•Special or Theme Issue (17)

•Tools/Toolkit (25)

•Web Resource (19)

Error Types

•Epidemiology of Errors and Adverse Events (455)

•Active Errors (306)

•Latent Errors (130)

•Near Miss (36)

Approach to Improving Safety

•Quality Improvement Strategies (515)

•Legal and Policy Approaches (136)

•Error Reporting and Analysis (560)

•Communication Improvement (390)

•Human Factors Engineering (242)

•Teamwork (120)

•Specialization of Care (113)

•Logistical Approaches (179)

•Culture of Safety (187)

•Technologic Approaches (332)

•Education and Training (326)

Clinical Areas

•Allied Health Services (5)

•Medicine (1165)

•Nursing (330)

•Pharmacy (363)

Target Audience

•Health Care Providers (1587)

•Health Care Executives and Administrators (1435)

•Non-Health Care Professionals (488)

•Patients (86)

Setting of Care

•Hospitals (1323)

•Psychiatric Facilities (7)

•Residential Facilities (20)

•Ambulatory Care (161)

•Outpatient Surgery (13)

•Patient Transport (7)

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COMMENTARY

Citrate Mix-Up

Weber RJ. AHRQ WebM&M [serial online]. May 2006.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:725-728.

COMMENTARY

It's All in the Syringe

Weingart SN. AHRQ WebM&M [serial online]. August 2006.

COMMENTARY

A Troubling Amine

Flynn EA. AHRQ WebM&M [serial online]. September 2006.

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

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

The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors in a UK intensive care unit.

Sanghera IS, Franklin BD, Dhillon S. Anaesthesia. 2007;62:53-61.

AUDIOVISUAL

Preventing fatal heparin overdoses.

Food and Drug Administration (FDA) Patient Safety News. Show #58. December 2006.

BOOK/REPORT

National Diabetes Inpatient Audit 2011.

Leeds, UK: Health and Social Care Information Centre; 2012.

COMMENTARY

ISMP medication error report analysis.

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

STUDY

Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes.

Alexander KP, Chen AY, Roe MT, et al; CRUSADE Investigators. JAMA. 2005;294:3108-3116.

STUDY

Detection and prevention of medication errors using real-time bedside nurse charting.

Nelson NC, Evans RS, Samore MH, Gardner RM. J Am Med Inform Assoc. 2005;12:390-397.

STUDY

Drug-induced hypoglycaemia--new insight into an old problem.

Ching CK, Lai CK, Poon WT, et al. Hong Kong Med J. 2006;12:334-338.

STUDY

Epidemiology, comparative methods of detection, and preventability of adverse drug events.

Al-Tajir GK, Kelly WN. Ann Pharmacother. 2005;39:1169-1174.

COMMENTARY

Crossed Coverage

Kayser SR. AHRQ WebM&M [serial online]. February 2007.

NEWSPAPER/MAGAZINE ARTICLE

Tablet splitting: Do it only if you "half" to, and then do it safely.

ISMP Medication Safety Alert! Acute Care Edition. May 18, 2006;11:1-2.

NEWSPAPER/MAGAZINE ARTICLE

Promethazine conundrum: IV can hurt more than IM injection!

ISMP Medication Safety Alert! Acute Care Edition. November 2, 2006;11:1-3.

COMMENTARY

Prescribing errors resulting in adverse drug events: how can they be prevented?

Thurmann PA. Expert Opin Drug Saf. 2006;5:489-493.

STUDY

A review of medication administration errors reported in a large psychiatric hospital in the United Kingdom.

Haw CM, Dickens G, Stubbs J. Psychiatr Serv. 2005;56:1610-1613.

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