AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (149)

•Diagnostic Errors (197)

•Identification Errors (106)

•Discontinuities, Gaps, and Hand-Off Problems (432)

•Fatigue and Sleep Deprivation (81)

•Medication Safety (1320)

•Medical Complications (435)

•Nonsurgical Procedural Complications (86)

•Surgical Complications (400)

•Transfusion Complications (23)

•Psychological and Social Complications (116)

Origin/Sponsor

•Africa (4)

•Asia (31)

•Australia and New Zealand (63)

•Central and South America (5)

•Europe (276)

•North America (3386)

Resource Types

•Clinical Guideline (9)

•Journal Article (2684)

•Legislation/Regulation (51)

•Meeting/Conference (35)

•Newsletter/Journal (17)

•Newspaper/Magazine Article (373)

•Press Release/Announcement (20)

•Special or Theme Issue (61)

•Tools/Toolkit (65)

•Web Resource (127)

•Grant (7)

Error Types

•Epidemiology of Errors and Adverse Events (1343)

•Active Errors (494)

•Latent Errors (191)

•Near Miss (68)

Approach to Improving Safety

•Quality Improvement Strategies (1148)

•Legal and Policy Approaches (388)

•Error Reporting and Analysis (1112)

•Communication Improvement (891)

•Human Factors Engineering (420)

•Teamwork (259)

•Specialization of Care (257)

•Logistical Approaches (260)

•Culture of Safety (494)

•Technologic Approaches (666)

•Education and Training (637)

Clinical Areas

•Allied Health Services (10)

Target Audience

•Health Care Providers (3035)

•Health Care Executives and Administrators (2919)

•Non-Health Care Professionals (1255)

•Patients (307)

Setting of Care

•Hospitals (2210)

•Psychiatric Facilities (16)

•Residential Facilities (128)

•Ambulatory Care (424)

•Outpatient Surgery (48)

•Patient Transport (30)

1 - 20 of 3787

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STUDY

Potentially inappropriate prescribing in older people with dementia in care homes: a retrospective analysis.

Parsons C, Johnston S, Mathie E, et al. Drugs Aging. 2012;29:143-155.

STUDY

Medication errors during patient transitions into nursing homes: characteristics and association with patient harm.

Desai R, Williams CE, Greene SB, Pierson S, Hansen RA. Am J Geriatr Pharmacother. 2011;9:413-422.

STUDY

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.

STUDY

Cause and effect analysis of closed claims in obstetrics and gynecology.

White AA, Pichert JW, Bledsoe SH, Irwin C, Entman SS. Obstet Gynecol. 2005;105:1031-1038.

STUDY

Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents.

Lau DT, Kasper JD, Potter DE, Lyles A, Bennett RG. Arch Intern Med. 2005;165:68-74.

STUDY

Dementia and risk of adverse warfarin-related events in the nursing home setting.

Tjia J, Field TS, Mazor KM, et al. Am J Geriatr Pharmacother. 2012;10:323-330.

STUDY

Medication reconciliation and hypertension control.

Persell SD, Bailey SC, Tang J, Davis TC, Wolf MS. Am J Med. 2010;123:182.e9-182.e15.

TOOLKIT

A Systems Approach to Quality Improvement in Long-Term Care: Safe Medication Practices Workbook.

Waltham, MA: Masspro, Massachusetts Coalition for the Prevention of Medical Errors, Massachusetts Extended Care Foundation; 2007.

REVIEW

Computerized physician order entry with clinical decision support in long-term care facilities: costs and benefits to stakeholders.

Subramanian S, Hoover S, Gilman B, Field TS, Mutter R, Gurwitz JH. J Am Geriatr Soc. 2007;55:1451-1457.

STUDY

Team safety and innovation by learning from errors in long-term care settings.

Buljac-Samardžić M, van Woerkom M, Paauwe J. Health Care Manag Rev. 2012;37:280-291.

STUDY

Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes.

Lapane KL, Hughes CM, Daiello LA, Cameron KA, Feinberg J. J Am Geriatr Soc. 2011;59:1238-1245.

STUDY

Assessing resident safety culture in nursing homes: using the nursing home survey on resident safety.

Castle NG, Wagner LM, Perera S, Ferguson JC, Handler SM. J Patient Saf. 2010;6:59-67.

STUDY

Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality improvement opportunities.

Hansen RA, Cornell PY, Ryan PB, Williams CE, Pierson S, Greene SB. Pharmacoepidemiol Drug Saf. 2010;19:1087-1094.

STUDY

Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting.

Gurwitz JH, Field TS, Rochon P, et al. J Am Geriatr Soc. 2008;56:2225-2233.

STUDY

Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork.

Vogelsmeier A, Scott-Cawiezell J. J Nurs Care Qual. 2011;26:236-242.

STUDY

The influence of formulation and medicine delivery system on medication administration errors in care homes for older people.

Alldred DP, Standage C, Fletcher O, et al. BMJ Qual Saf. 2011;20:397-402.

STUDY

The impact of computerized provider order entry on medication errors in a multispecialty group practice.

Devine EB, Hansen RN, Wilson-Norton JL, et al. J Am Med Inform Assoc. 2010;17:78-84.

STUDY

Emergency department medication lists are not accurate.

Caglar S, Henneman PL, Blank FS, Smithline HA, Henneman EA. J Emerg Med. 2011;40:613-616.

STUDY

Barriers and facilitators to communicating nursing errors in long-term care settings.

Wagner LM, Damianakis T, Pho L, Tourangeau A. J Patient Saf. 2013;9:1-7.

STUDY

Health outcomes associated with potentially inappropriate medication use in older adults.

Fick DM, Mion LC, Beers MH, Waller JL. Res Nurs Health. 2008;31:42-51.

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