AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (142)

•Diagnostic Errors (138)

•Identification Errors (109)

•Discontinuities, Gaps, and Hand-Off Problems (328)

•Fatigue and Sleep Deprivation (112)

•Medication Safety (1176)

•Medical Complications (274)

•Nonsurgical Procedural Complications (52)

•Surgical Complications (345)

•Transfusion Complications (17)

•Psychological and Social Complications (119)

Origin/Sponsor

•Asia (29)

•Australia and New Zealand (43)

•Central and South America (3)

•Europe (168)

•North America (3244)

Resource Types

•Clinical Guideline (7)

•Journal Article (2497)

•Legislation/Regulation (50)

•Meeting/Conference (31)

•Newsletter/Journal (10)

•Newspaper/Magazine Article (459)

•Press Release/Announcement (24)

•Special or Theme Issue (71)

•Tools/Toolkit (41)

•Web Resource (68)

•Grant (8)

Error Types

•Epidemiology of Errors and Adverse Events (605)

•Active Errors (437)

•Latent Errors (203)

•Near Miss (53)

Approach to Improving Safety

•Quality Improvement Strategies (850)

•Legal and Policy Approaches (383)

•Error Reporting and Analysis (886)

•Communication Improvement (726)

•Human Factors Engineering (615)

•Teamwork (257)

•Specialization of Care (208)

•Logistical Approaches (318)

•Culture of Safety (506)

•Technologic Approaches (892)

•Education and Training (620)

Clinical Areas

•Allied Health Services (8)

Target Audience

•Health Care Providers (2671)

•Health Care Executives and Administrators (2851)

•Non-Health Care Professionals (1479)

•Patients (242)

Setting of Care

•Hospitals (1986)

•Psychiatric Facilities (11)

•Residential Facilities (58)

•Ambulatory Care (265)

•Outpatient Surgery (26)

•Patient Transport (10)

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STUDY

A trial of automated decision support alerts for contraindicated medications using computerized physician order entry.

Galanter WL, Didomenico RJ, Polikaitis A. J Am Med Inform Assoc. 2005;12:269-274.

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.

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

Evaluation of a Web-based education program on reducing medication dosing error: a multicenter, randomized controlled trial.

Frush K, Hohenhaus S, Luo X, Gerardi M, Wiebe RA. Pediatr Emerg Care. 2006;22:62-70.

STUDY

Nurse interruptions pre- and post-implementation of a point-of-care medication administration system.

Stamp KD, Willis DG. J Nurs Care Qual. 2010;25:231-239.

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

Medication Administration Time Study (MATS): nursing staff performance of medication administration.

Elganzouri ES, Standish CA, Androwich I. J Nurs Adm. 2009;39:204-210.

STUDY

Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.

Colligan L, Guerlain S, Steck SE, Hoke TR. BMJ Qual Saf. 2012;21:939-947.

NEWSPAPER/MAGAZINE ARTICLE

Clear liquids may place patients at risk.

PA-PSRS Patient Saf Advis. December 2005;2:29-31.

NEWSPAPER/MAGAZINE ARTICLE

Design for reliability: barcoded medication administration.

Hayden AC, Lanoue ET, Still CJ. Patient Saf Qual Healthc. July/August 2011;8:12-20.

NEWSPAPER/MAGAZINE ARTICLE

Tomorrow's operating room to harness Net, RFID.

Olsen S. CNET News.com; October 19, 2005.

NEWSPAPER/MAGAZINE ARTICLE

Medication administration in anesthesia: time for a paradigm shift.

Stabile M, Webster CS, Merry AF. APSF Newsletter. Fall 2007;22:44-47.

FACT SHEET/FAQS

Oral Dosage Forms that Should Not Be Crushed.

Mitchell JF. Institute for Safe Medication Practices.

STUDY

Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error.

Goodman EJ, Haas AJ, Kantor GS. Int J Obstet Anesth. 2006;15:63-67.

NEWSPAPER/MAGAZINE ARTICLE

IV potassium given epidurally: getting to the "route" of the problem.

ISMP Medication Safety Alert! Acute Care Edition. April 6, 2006;11:1-2.

TOOLKIT

Looking Collectively at Risk.

Pathways for Medication Safety Tool #2. Chicago, IL: American Hospital Association; 2003.

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.

COMMENTARY

IV medication safety software implementation in a multihospital health system.

Cassano AT. Hosp Pharm. 2006;41:151-156.

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

Workarounds to barcode medication administration systems: their occurrences, causes, and threats to patient safety.

Koppel R, Wetterneck T, Telles JL, Karsh BT. J Am Med Inform Assoc. 2008;15:408-423.

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