AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (180)

•Diagnostic Errors (143)

•Identification Errors (114)

•Discontinuities, Gaps, and Hand-Off Problems (515)

•Fatigue and Sleep Deprivation (103)

•Medication Safety (1149)

•Medical Complications (544)

•Nonsurgical Procedural Complications (101)

•Surgical Complications (514)

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Resource Types

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Error Types

•Epidemiology of Errors and Adverse Events (1136)

•Active Errors (601)

•Latent Errors (271)

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Approach to Improving Safety

•Quality Improvement Strategies (933)

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•Communication Improvement (953)

•Human Factors Engineering (509)

•Teamwork (347)

•Specialization of Care (351)

•Logistical Approaches (337)

•Culture of Safety (528)

•Technologic Approaches (673)

•Education and Training (730)

Clinical Areas

•Allied Health Services (3)

•Medicine (2962)

•Nursing (382)

•Pharmacy (420)

Target Audience

•Health Care Providers (2581)

•Health Care Executives and Administrators (3067)

•Non-Health Care Professionals (1340)

•Patients (313)

Setting of Care
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Hospitals

•General Hospitals (1349)

•Children’s Hospitals (153)

•Specialty Hospitals (80)

1 - 20 of 3862

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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

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.

NEWSPAPER/MAGAZINE ARTICLE

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

STUDY

Supratherapeutic dosing of acetaminophen among hospitalized patients.

Zhou L, Maviglia SM, Mahoney LM, et al. Arch Intern Med. 2012;172:1721-1728.

REVIEW

A systematic review of failures in handoff communication during intrahospital transfers.

Ong MS, Coiera E. Jt Comm J Qual Patient Saf. 2011;37:274-284.

STUDY

Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge.

Ziaeian B, Araujo KLB, Van Ness PH, Horwitz LI. J Gen Intern Med. 2012;27:1513-1520.

STUDY

Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System.

Metersky ML, Hunt DR, Kliman R, et al. Med Care. 2011;49:504-510.

STUDY

Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.

Brady PW, Muething S, Kotagal U, et al. Pediatrics. 2013;131:e298-e308.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

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

STUDY

Parenteral nutrition prescribing processes using computerized prescriber order entry: opportunities to improve safety.

Hilmas E, Peoples JD. JPEN J Parenter Enteral Nutr. 2012;36(suppl 2):32S-35S.

STUDY

A July spike in fatal medication errors: a possible effect of new medical residents.

Phillips DP, Barker GEC. J Gen Intern Med. 2010;25:774-779.

STUDY

Effect of patient- and medication-related factors on inpatient medication reconciliation errors.

Salanitro AH, Osborn CY, Schnipper JL, et al. J Gen Intern Med. 2012;27:924-932.

STUDY

Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system.

Mattison MLP, Afonso KA, Ngo LH, Mukamal KJ. Arch Intern Med. 2010;170:1331-1336.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.

STUDY

The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries.

Press MJ, Silber JH, Rosen AK, et al. J Gen Intern Med. 2011;26:405-411.

COMMENTARY

Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue.

Young JQ, Wachter RM. JAMA. 2009;302:1327-1329.

STUDY

Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents.

Redwood S, Rajakumar A, Hodson J, Coleman JJ. BMC Med Inform Decis Mak. 2011;11:29.

STUDY

The costs of adverse drug events in community hospitals.

Hug BL, Keohane C, Seger DL, Yoon C, Bates DW. Jt Comm J Qual Patient Saf. 2012;38:120-126.

NEWSPAPER/MAGAZINE ARTICLE

Patients taking their own medications while in the hospital.

PA-PSRS Patient Saf Advis. June 2012;9:50-57.

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