AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (95)

•Diagnostic Errors (100)

•Identification Errors (58)

•Discontinuities, Gaps, and Hand-Off Problems (618)

•Fatigue and Sleep Deprivation (82)

•Medication Safety (1161)

•Medical Complications (228)

•Nonsurgical Procedural Complications (26)

•Surgical Complications (153)

•Transfusion Complications (10)

•Psychological and Social Complications (87)

Origin/Sponsor

•Asia (8)

•Australia and New Zealand (36)

•Central and South America (2)

•Europe (107)

•North America (2628)

Resource Types

•Clinical Guideline (2)

•Journal Article (1803)

•Legislation/Regulation (41)

•Meeting/Conference (32)

•Newsletter/Journal (12)

•Newspaper/Magazine Article (429)

•Press Release/Announcement (28)

•Special or Theme Issue (56)

•Tools/Toolkit (62)

•Web Resource (69)

•Grant (9)

Error Types

•Epidemiology of Errors and Adverse Events (486)

•Active Errors (289)

•Latent Errors (191)

•Near Miss (31)

Approach to Improving Safety

•Quality Improvement Strategies (707)

•Legal and Policy Approaches (358)

•Error Reporting and Analysis (701)

•Communication Improvement (858)

•Human Factors Engineering (304)

•Teamwork (187)

•Specialization of Care (225)

•Logistical Approaches (199)

•Culture of Safety (432)

•Technologic Approaches (575)

•Education and Training (521)

Clinical Areas

•Allied Health Services (11)

Target Audience

•Health Care Providers (1928)

•Health Care Executives and Administrators (2252)

•Non-Health Care Professionals (1105)

•Patients (271)

Setting of Care

•Hospitals (1547)

•Psychiatric Facilities (10)

•Residential Facilities (53)

•Ambulatory Care (303)

•Outpatient Surgery (21)

•Patient Transport (18)

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COMMENTARY

Medication reconciliation physician order form.

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

NEWSPAPER/MAGAZINE ARTICLE

Fixing the medication reconciliation breakdown.

Starr D, West L. Most Wired Magazine. November 9, 2006.

NEWSPAPER/MAGAZINE ARTICLE

JCAHO tightens leash on medication reconciliation.

Perry LE. Drug Topics: Health-System Edition. March 20, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Practitioners agree on medication reconciliation value, but frustration and difficulties abound.

ISMP Medication Safety Alert! Acute Care Edition. July 13, 2006;11:1-2.

STUDY

Implementation of an electronic system for medication reconciliation.

Kramer JS, Hopkins PJ, Rosendale JC, et al. Am J Health Syst Pharm. 2007;64:404-422.

COMMENTARY

Using pharmacogenetics to improve drug safety and efficacy.

Haga SB, Burke W. JAMA. 2004;291:2869-2871.

NEWSPAPER/MAGAZINE ARTICLE

Accuracy at every step: the challenge of medication reconciliation.

Institute for Healthcare Improvement Web site. March 20, 2006.

COMMENTARY

What medications does your patient take? Enhancing medication safety in the outpatient setting.

Institute for Healthcare Improvement. March 14, 2007.

NEWSPAPER/MAGAZINE ARTICLE

Survey results: community liaison programs to decrease hospital readmissions.

ISMP Medication Safey Alert! Acute Care Edition. March 7, 2013;18:1-3.

NEWSPAPER/MAGAZINE ARTICLE

The five rights: a destination without a map.

ISMP Medication Safety Alert! Acute Care Edition. January 25, 2007;12:1.

STUDY

Language barriers to prescriptions for patients with limited English proficiency: a survey of pharmacies.

Bradshaw M, Tomany-Korman S, Flores G. Pediatrics. 2007;120:e225-e235.

STUDY

Medication reconciliation: developing and implementing a program.

Schwarz M, Wyskiel R. Crit Care Nurs Clin North Am. 2006;18:503-507.

STUDY

Availability of Spanish prescription labels.

Sharif I, Lo S, Ozuah PO. J Health Care Poor Underserved. 2006;17:65-69.

DATABASE/DIRECTORY

Horsham, PA: Institute for Safe Medication Practices; 2011.

STUDY

Medication reconciliation for reducing drug-discrepancy adverse events.

Boockvar KS, Carlson Lacorte H, Giambanco V, Fridman B, Siu A. Am J Geriatr Pharmacother. 2006;4:236-243.

BOOK/REPORT

Medication Needs During Transitions May Not Be Managed for All Servicemembers.

Washington, DC: United States Government Accountability Office; November 2, 2012. Publication GAO-13-26.

COMMENTARY

Teaching medication reconciliation through simulation: a patient safety initiative for second year medical students.

Lindquist LA, Gleason KM, McDaniel MR, Doeksen A, Liss D. J Gen Intern Med. 2008;23:998-1001.

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.

NEWSPAPER/MAGAZINE ARTICLE

Five hospitals release data on inspections.

Kowalczyk L. Boston Globe. April 21, 2007:B1.

NEWSPAPER/MAGAZINE ARTICLE

Legality of technicians' involvement in medication reconciliation not clear.

Thompson CA. AJHP News. Am J Health Syst Pharm. 2009;66:433-434.

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