AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (217)

•Diagnostic Errors (238)

•Identification Errors (144)

•Discontinuities, Gaps, and Hand-Off Problems (531)

•Fatigue and Sleep Deprivation (98)

•Medication Safety (1720)

•Medical Complications (558)

•Nonsurgical Procedural Complications (115)

•Surgical Complications (524)

•Transfusion Complications (30)

•Psychological and Social Complications (141)

Origin/Sponsor

•Australia and New Zealand (127)

•Central and South America (10)

•Europe (530)

•North America (4060)

Resource Types

•Audiovisual (47)

•Bibliography (2)

•Book/Report (229)

•Clinical Guideline (8)

•Journal Article (3685)

•Legislation/Regulation (57)

•Meeting/Conference (34)

•Newsletter/Journal (12)

•Newspaper/Magazine Article (446)

•Press Release/Announcement (31)

•Special or Theme Issue (70)

•Tools/Toolkit (60)

•Web Resource (112)

Error Types

•Epidemiology of Errors and Adverse Events (1526)

•Active Errors (730)

•Latent Errors (285)

•Near Miss (92)

Approach to Improving Safety

•Quality Improvement Strategies (1097)

•Legal and Policy Approaches (391)

•Error Reporting and Analysis (1395)

•Communication Improvement (1090)

•Human Factors Engineering (662)

•Teamwork (370)

•Specialization of Care (343)

•Logistical Approaches (341)

•Culture of Safety (533)

•Technologic Approaches (1064)

•Education and Training (844)

Clinical Areas

•Allied Health Services (12)

•Dentistry (5)

•Medicine (3232)

•Nursing (427)

•Pharmacy (644)

Target Audience

•Health Care Providers (3702)

•Health Care Executives and Administrators (3849)

•Non-Health Care Professionals (1827)

•Patients (333)

Setting of Care

•Hospitals (2970)

•Psychiatric Facilities (18)

•Residential Facilities (88)

•Ambulatory Care (474)

•Outpatient Surgery (50)

•Patient Transport (37)

1 - 20 of 4839

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STUDY

Risk of adverse drug events in neonates treated with opioids and the effect of a bar-code–assisted medication administration system.

Morriss FH, Jr, Abramowitz PW, Nelson SP, Milavetz G, Michael SL, Gordon SN. Am J Health Syst Pharm. 2011;68:57-62.

STUDY

Prevalence of adverse events in pediatric intensive care units in the United States.

Agarwal S, Classen D, Larsen G, et al. Pediatr Crit Care Med. 2010;11:568-578.

STUDY

Toward learning from patient safety reporting systems.

Pronovost PJ, Thompson DA, Holzmueller CG, et al. J Crit Care. 2006;21:305-315.

STUDY

classic

Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases.

Bell CM, Brener SS, Gunraj N, et al. JAMA. 2011;306:840-847.

STUDY

Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration.

Yamamoto L, Kanemori J. Am J Emerg Med. 2010;28:588-592.

COMMENTARY

A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.

Carspecken CW, Sharek PJ, Longhurst C, Pageler NM. Pediatrics. 2013;131:e1970-e1973.

STUDY

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.

STUDY

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit.

Stavroudis TA, Shore AD, Morlock L, Hicks RW, Bundy D, Miller MR. J Perinatol. 2010;30:459-468.

STUDY

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.

STUDY

Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit.

Buckley MS, Erstad BL, Kopp BJ, Theodorou AA, Priestley G. Pediatr Crit Care Med. 2007;8:145-152.

NEWSPAPER/MAGAZINE ARTICLE

Another tragic parenteral nutrition compounding error.

ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.

NEWSPAPER/MAGAZINE ARTICLE

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

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

STUDY

Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports.

Snijders C, van Lingen RA, Klip H, Fetter WP, van der Schaaf TW, Molendijk HA, NEOSAFE study group. Arch Dis Child Fetal Neonatal Ed. 2009;94:F210-F215.

STUDY

Pediatric safety incidents from an intensive care reporting system.

Skapik JL, Pronovost PJ, Miller MR, Thompson DA, Wu AW. J Patient Saf. 2009;5:95-101.

STUDY

Adverse drug event reporting in intensive care units: a survey of current practices.

Kane-Gill SL, Devlin JW. Ann Pharmacother. 2006;40:1267-73.

STUDY

Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events.

Nuckols TK, Bower AG, Paddock SM, et al. J Gen Intern Med. 2008;23(suppl 1):41-45.

REVIEW

Computerized physician order entry in the critical care environment: a review of current literature.

Maslove DM, Rizk N, Lowe HJ. J Intensive Care Med. 2011;26:165-171.

STUDY

A comparison of voluntarily reported medication errors in intensive care and general care units.

Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.

SPECIAL OR THEME ISSUE

Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit.

Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(suppl 6):S83-S264.

STUDY

Effect of bar-code–assisted medication administration on medication administration errors and accuracy in multiple patient care areas.

Helmons PJ, Wargel LN, Daniels CE. Am J Health Syst Pharm. 2009;66:1202-1210.

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