AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (234)

•Diagnostic Errors (218)

•Identification Errors (158)

•Discontinuities, Gaps, and Hand-Off Problems (545)

•Fatigue and Sleep Deprivation (115)

•Medication Safety (1736)

•Medical Complications (568)

•Nonsurgical Procedural Complications (108)

•Surgical Complications (473)

•Transfusion Complications (33)

•Psychological and Social Complications (176)

Origin/Sponsor

•Africa (7)

•Asia (57)

•Australia and New Zealand (118)

•Central and South America (8)

•Europe (462)

•North America (4432)

Resource Types

•Clinical Guideline (9)

•Journal Article (3508)

•Legislation/Regulation (72)

•Meeting/Conference (49)

•Newsletter/Journal (14)

•Newspaper/Magazine Article (658)

•Press Release/Announcement (55)

•Special or Theme Issue (80)

•Tools/Toolkit (92)

•Web Resource (155)

•Grant (15)

Error Types

•Epidemiology of Errors and Adverse Events (1076)

•Active Errors (888)

•Latent Errors (364)

•Near Miss (91)

Approach to Improving Safety

•Quality Improvement Strategies (1276)

•Legal and Policy Approaches (631)

•Error Reporting and Analysis (1423)

•Communication Improvement (1211)

•Human Factors Engineering (775)

•Teamwork (378)

•Specialization of Care (367)

•Logistical Approaches (389)

•Culture of Safety (747)

•Technologic Approaches (998)

•Education and Training (967)

Clinical Areas

•Allied Health Services (17)

Target Audience

•Health Care Providers (3746)

•Health Care Executives and Administrators (3999)

•Non-Health Care Professionals (1934)

•Patients (513)

Setting of Care

•Hospitals (3364)

•Psychiatric Facilities (20)

•Residential Facilities (91)

•Ambulatory Care (464)

•Outpatient Surgery (46)

•Patient Transport (38)

1 - 20 of 5174

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NEWSPAPER/MAGAZINE ARTICLE

Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.

ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: a year in review.

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

NEWSPAPER/MAGAZINE ARTICLE

Medication errors occurring with the use of bar-code administration technology.

PA-PSRS Patient Saf Advis. December 2008;5:122-126.

COMMENTARY

The Role of Bar Coding and Smart Pumps in Safety

Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN AHRQ WebM&M [serial online]. September 2008.

STUDY

Intravenous infusion safety technology: return on investment.

Danello SH, Maddox RR, Schaack GJ. Hosp Pharm. 2009;44:680-687, 696.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

ISMP Medication Safety Alert! Acute Care Edition. May 3, 2007;12:1-2.

COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

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

Anticoagulant safety practices call for pharmacist supervision.

Scott A. Drug Topics (Health-System Edition). November 10, 2008.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:937-938, 945.

STUDY

The rate and costs attributable to intravenous patient-controlled analgesia errors.

Meissner B, Nelson W, Hicks R, Sikirica V, Gagne J, Schein J. Hosp Pharm. 2009;44:312–324.

BOOK/REPORT

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.

Toft B. London, England: Department of Health; 2001.

NEWSPAPER/MAGAZINE ARTICLE

Heparin overdose in three infants revisits hospital error issues.

Phend C. MedPage Today. November 26, 2007.

NEWSPAPER/MAGAZINE ARTICLE

Beware of basal opioid infusions with PCA therapy.

ISMP Medication Safety Alert! Acute Care Edition. March 12, 2009;14:1-3.

MEASUREMENT TOOL/INDICATOR

Medication Safety Self Assessment for Automated Dispensing Cabinets.

Horsham, PA: Institute for Safe Medication Practices; 2009.

STUDY

Origins of and solutions for neonatal medication-dispensing errors.

Sauberan JB, Dean LM, Fiedelak J, Abraham JA. Am J Health Syst Pharm. 2010;67:49-57.

NEWSPAPER/MAGAZINE ARTICLE

ISMP updates its list of drug name pairs with Tall man letters.

ISMP Medication Safety Alert! Acute Care Edition. November 18, 2010;15:1-3.

STUDY

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2008.

Pedersen CA, Schneider P, Scheckelhoff DJ. Am J Health Syst Pharm. 2009;66:926-946.

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