AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (105)

•Diagnostic Errors (57)

•Identification Errors (68)

•Discontinuities, Gaps, and Hand-Off Problems (337)

•Fatigue and Sleep Deprivation (88)

•Medication Safety (1322)

•Medical Complications (309)

•Nonsurgical Procedural Complications (34)

•Surgical Complications (145)

•Transfusion Complications (18)

•Psychological and Social Complications (70)

Origin/Sponsor

•Africa (1)

•Asia (26)

•Australia and New Zealand (30)

•Central and South America (3)

•Europe (103)

•North America (2559)

Resource Types

•Audiovisual (45)

•Award (19)

•Book/Report (122)

•Clinical Guideline (5)

•Journal Article (1880)

•Legislation/Regulation (35)

•Meeting/Conference (12)

•Newsletter/Journal (5)

•Newspaper/Magazine Article (484)

•Press Release/Announcement (12)

•Special or Theme Issue (21)

•Tools/Toolkit (50)

•Web Resource (46)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (654)

•Active Errors (372)

•Latent Errors (176)

•Near Miss (51)

Approach to Improving Safety

•Quality Improvement Strategies (639)

•Legal and Policy Approaches (291)

•Error Reporting and Analysis (754)

•Communication Improvement (623)

•Human Factors Engineering (321)

•Teamwork (130)

•Specialization of Care (255)

•Logistical Approaches (265)

•Culture of Safety (335)

•Technologic Approaches (662)

•Education and Training (455)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (1792)

•Health Care Executives and Administrators (2002)

•Non-Health Care Professionals (883)

•Patients (289)

Setting of Care

•Hospitals (2146)

•Psychiatric Facilities (9)

•Residential Facilities (58)

•Ambulatory Care (288)

•Outpatient Surgery (21)

•Patient Transport (9)

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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.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

NEWSPAPER/MAGAZINE ARTICLE

Point-of-care medication error prevention: best practices in action.

Swenson D. Patient Saf Qual Healthc. May/June 2007;4:18-25.

NEWSPAPER/MAGAZINE ARTICLE

Dose of technology helps Shands at UF avoid drug errors.

Chun D. Gainsville Sun. August 21, 2006.

ORGANIZATIONAL POLICY/GUIDELINES

ASHP statement on bar-code verification during inventory, preparation, and dispensing of medications.

Am J Health Syst Pharm. 2011;68:442-445.

BOOK/REPORT

Pharmacist Staffing and the Use of Technology in Small Rural Hospitals: Implications for Medication Safety.

Casey MM, Moscovice I, Davidson G. Upper Midwest Rural Health Research Center; December 2005.

NEWSPAPER/MAGAZINE ARTICLE

Experts offer smart tips for smart pumps.

Gebhart F. Drug Topics (Health-System Edition). July 23, 2007.

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.

STUDY

Internal reporting system to improve a pharmacy's medication distribution process.

Rickrode GA, Williams-Lowe ME, Rippe JL, Theriault RH Jr. Am J Health Syst Pharm. 2007;64:1197-1202.

COMMENTARY

Implementation of a specialized pharmacy team to monitor high-risk medications during discharge.

Martin ES III, Overstreet RL, Jackson-Khalil LR, McCollough HL, Meyer TA, Xu Q. Am J Health Syst Pharm. 2013;70:18-21.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2007;42:498-499.

REVIEW

Systematic review of medication safety assessment methods.

Meyer-Massetti C, Cheng CM, Schwappach DL, et al. Am J Health Syst Pharm. 2011;68:227-240.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2007;42:884–888.

STUDY

Frequency of HIV-related medication errors and associated risk factors in hospitalized patients.

Pastakia SD, Corbett AH, Raasch RH, Napravnik S, Correll TA. Ann Pharmacother. 2008;42:491-497.

STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

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.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:960-964.

REVIEW

Clinical pharmacists and inpatient medical care: a systematic review.

Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Arch Intern Med. 2006;166:955-964.

STUDY

Use of specific indicators to detect warfarin-related adverse events.

Hartis CE, Gum MO, Lederer JW Jr. Am J Health Syst Pharm. 2005;62:1683-1688.

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