AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (93)

•Diagnostic Errors (139)

•Identification Errors (61)

•Discontinuities, Gaps, and Hand-Off Problems (251)

•Fatigue and Sleep Deprivation (97)

•Medication Safety (777)

•Medical Complications (197)

•Nonsurgical Procedural Complications (43)

•Surgical Complications (251)

•Transfusion Complications (9)

•Psychological and Social Complications (102)

Origin/Sponsor

•Africa (1)

•Asia (9)

•Australia and New Zealand (13)

•Central and South America (2)

•Europe (92)

•North America (2474)

Resource Types

•Clinical Guideline (5)

•Journal Article (1783)

•Legislation/Regulation (40)

•Meeting/Conference (24)

•Newsletter/Journal (9)

•Newspaper/Magazine Article (374)

•Press Release/Announcement (13)

•Special or Theme Issue (42)

•Tools/Toolkit (34)

•Web Resource (54)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (456)

•Active Errors (273)

•Latent Errors (127)

•Near Miss (35)

Approach to Improving Safety

•Quality Improvement Strategies (685)

•Legal and Policy Approaches (349)

•Error Reporting and Analysis (723)

•Communication Improvement (562)

•Human Factors Engineering (248)

•Teamwork (181)

•Specialization of Care (174)

•Logistical Approaches (203)

•Culture of Safety (401)

•Technologic Approaches (561)

•Education and Training (485)

Clinical Areas

•Allied Health Services (6)

Target Audience

•Health Care Providers (1954)

•Health Care Executives and Administrators (2096)

•Non-Health Care Professionals (1047)

•Patients (207)

Setting of Care

•Hospitals (1429)

•Psychiatric Facilities (7)

•Residential Facilities (33)

•Ambulatory Care (230)

•Outpatient Surgery (23)

•Patient Transport (7)

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STUDY

Chemotherapy dose limits set by users of a computer order entry system.

DuBeshter B, Griggs J, Angel C, Loughner J. Hosp Pharm. 2006;41:136-142.

STUDY

Chemotherapy medication errors in a pediatric cancer treatment center: prospective characterization of error types and frequency and development of a quality improvement initiative to lower the error rate.

Watts RG, Parsons K. Pediatr Blood Cancer. 2013 Mar 20; [Epub ahead of print].

STUDY

Medication safety in the ambulatory chemotherapy setting.

Gandhi TK, Bartel SB, Shulman LN, et al. Cancer. 2005;104:2477-2483.

COMMENTARY

Preventing vincristine administration errors: does evidence support minibag infusions?

Schulmeister L. Clin J Oncol Nurs. 2006;10:271-273.

NEWSPAPER/MAGAZINE ARTICLE classic

Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused death of Globe columnist, damage to second woman.

Knox RA. The Boston Globe. March 23, 1995; Metro/Region section: 1.

STUDY

Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety.

Collins CM, Elsaid KA. Int J Qual Health Care. 2011;23:36-43.

BOOK/REPORT

The Prescription Infrastructre: Are We Ready for ePrescribing?

Sarasohn-Kahn J, Holt M. Oakland, CA: California Healthcare Foundation; 2006. ISBN: 1933795026.

STUDY

Using CPOE to improve communication, safety, and policy compliance when ordering pediatric chemotherapy.

Crossno CL, Cartwright JA, Hargrove FR. Hosp Pharm. 2007;42:368–373.

STUDY

Physician communication when prescribing new medications.

Tarn DM, Heritage J, Paterniti DA, Hays RD, Kravitz RL, Wenger NS. Arch Intern Med. 2006;166:1855-1862.

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.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing vincristine administration errors.

The Joint Commission. Sentinel Event Alert. July 14, 2005;(34):1-3.

STUDY

The story behind the story: physician skepticism about relying on clinical information technologies to reduce medical errors.

McAlearney AS, Chisolm DJ, Schweikhart S, Medow MA, Kelleher K. Int J Med Inf. 2007;76:836-842.

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

Fatality involving vinblastine overdose as a result of a complex medical error.

Klys M, Konopka T, Scislowski M, Kowalski P. Cancer Chemother Pharmacol. 2007;59:89-95.

TOOLKIT

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

Florida Health Care Coalition.

NEWSPAPER/MAGAZINE ARTICLE

IV vincristine survey shows safety improvements needed.

ISMP Medication Safety Alert! Acute Care Edition. February 23, 2006;11:1-2.

NEWSPAPER/MAGAZINE ARTICLE

The right dose of technology helps the medicine go down.

Patton S. CIO Magazine. November 1, 2005.

STUDY

Characteristics of medication errors with parenteral cytotoxic drugs.

Fyhr A, Akselsson R. Eur J Cancer Care (Engl). 2012;21:606-613.

COMMENTARY

Medication orders are written clearly and transcribed accurately – implementing Medication Management Standard 3.20 and National Patient Safety Goal 2b.

Laselle TJ,May SK. Hosp Pharm. 2006;41:82-87.

NEWSPAPER/MAGAZINE ARTICLE

Cause of death: sloppy doctors.

Caplan J. Time.com. January 15, 2007.

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