AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (120)

•Diagnostic Errors (128)

•Identification Errors (75)

•Discontinuities, Gaps, and Hand-Off Problems (330)

•Fatigue and Sleep Deprivation (113)

•Medication Safety (1110)

•Medical Complications (277)

•Nonsurgical Procedural Complications (50)

•Surgical Complications (322)

•Transfusion Complications (9)

•Psychological and Social Complications (121)

Origin/Sponsor

•Asia (18)

•Australia and New Zealand (37)

•Central and South America (2)

•Europe (152)

•North America (3073)

Resource Types

•Clinical Guideline (7)

•Journal Article (2381)

•Legislation/Regulation (43)

•Meeting/Conference (27)

•Newsletter/Journal (10)

•Newspaper/Magazine Article (425)

•Press Release/Announcement (21)

•Special or Theme Issue (53)

•Tools/Toolkit (41)

•Web Resource (62)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (598)

•Active Errors (389)

•Latent Errors (167)

•Near Miss (56)

Approach to Improving Safety

•Quality Improvement Strategies (839)

•Legal and Policy Approaches (383)

•Error Reporting and Analysis (864)

•Communication Improvement (734)

•Human Factors Engineering (358)

•Teamwork (250)

•Specialization of Care (249)

•Logistical Approaches (292)

•Culture of Safety (501)

•Technologic Approaches (639)

•Education and Training (628)

Clinical Areas

•Allied Health Services (11)

Target Audience

•Health Care Providers (2623)

•Health Care Executives and Administrators (2638)

•Non-Health Care Professionals (1213)

•Patients (221)

Setting of Care

•Hospitals (1957)

•Psychiatric Facilities (11)

•Residential Facilities (45)

•Ambulatory Care (269)

•Outpatient Surgery (23)

•Patient Transport (9)

1 - 20 of 3310

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COMMENTARY

ISMP medication error report analysis.

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

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

Errors associated with medications removed from automated dispensing machines using override functions.

Kester K, Baxter J, Freudenthal K. Hosp Pharm. 2006;41:535-537.

TOOLKIT

POP (Paul O’Neill Pledge) Patient Safety Campaign.

Florida Health Care Coalition.

TOOLKIT

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

Huntington Valley, PA: Institute for Safe Medication Practices.

STUDY

Antiretroviral medication errors in a national medication error database.

Gray J, Hicks RW, Hutchings C. AIDS Patient Care STDS. 2005;19:803-812.

NEWSPAPER/MAGAZINE ARTICLE

Clear liquids may place patients at risk.

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

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

High incidence of medication documentation errors in a Swiss university hospital due to the handwritten prescription process.

Hartel MJ, Staub LP, Röder C, Eggli S. BMC Health Serv Res. 2011;11:199.

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.

STUDY

The impact of abbreviations on patient safety.

Brunetti L, Santell JP, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:576-583.

STUDY

Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin.

Donihi AC, DiNardo MM, DeVita MA, Korytkowski MT. Qual Saf Health Care. 2006;15:89-91.

STUDY

Assessing and monitoring override medications in automated dispensing devices.

Kowiatek JG, Weber RJ, Skledar SJ, Frank S, DeVita M. Jt Comm J Qual Patient Saf. 2006;32:309-317.

STUDY

Potentially inappropriate prescribing in elderly veterans: are we using the wrong drug, wrong dose, or wrong duration?

Pugh MJ, Fincke BG, Bierman AS, et al. J Am Geriatr Soc. 2005;53:1282-1289.

NEWSPAPER/MAGAZINE ARTICLE

"Near injury" alters procedures at Virginia Mason.

Ostrom CM. The Seattle Times. May 21, 2005.

STUDY

Assessing the anticipated consequences of computer-based provider order entry at three community hospitals using an open-ended, semi-structured survey instrument.

Sittig DF, Ash JS, Guappone KP, Campbell EM, Dykstra RH. Int J Med Inform. 2008;77:440-447.

COMMENTARY

Medication reconciliation physician order form.

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

COMMENTARY

ISMP medication error report analysis.

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

STUDY

Risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a children's hospital.

Leonard MS, Cimino M, Shaha S, McDougal S, Pilliod J, Brodsky L. Pediatrics. 2006;118:e1124-e1129.

NEWSPAPER/MAGAZINE ARTICLE

Improving the safety of telephone or verbal orders.

PA-PSRS Patient Saf Advis. June 2006;3:1-5.

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