AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (164)

•Diagnostic Errors (113)

•Identification Errors (101)

•Discontinuities, Gaps, and Hand-Off Problems (456)

•Fatigue and Sleep Deprivation (93)

•Medication Safety (1082)

•Medical Complications (529)

•Nonsurgical Procedural Complications (97)

•Surgical Complications (441)

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Resource Types

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Error Types

•Epidemiology of Errors and Adverse Events (898)

•Active Errors (537)

•Latent Errors (243)

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Approach to Improving Safety

•Quality Improvement Strategies (844)

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•Error Reporting and Analysis (937)

•Communication Improvement (825)

•Human Factors Engineering (477)

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•Specialization of Care (334)

•Logistical Approaches (307)

•Culture of Safety (454)

•Technologic Approaches (668)

•Education and Training (661)

Clinical Areas

•Allied Health Services (5)

•Medicine (2569)

•Nursing (349)

•Pharmacy (400)

Target Audience

•Health Care Providers (2406)

•Health Care Executives and Administrators (2765)

•Non-Health Care Professionals (1220)

•Patients (294)

Setting of Care
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Hospitals

•General Hospitals (1098)

•Children’s Hospitals (136)

•Specialty Hospitals (73)

1 - 20 of 3441

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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

Impact of health information technology on detection of potential adverse drug events at the ordering stage.

Roberts LL, Ward MM, Brokel JM, Wakefield DS, Crandall DK, Conlon P. Am J Health Syst Pharm. 2010;67:1838-1846.

STUDY

From research to practice: factors affecting implementation of prospective targeted injury-detection systems.

Sorensen AV, Harrison MI, Kane HL, Roussel AE, Halpern MT, Bernard SL. BMJ Qual Saf. 2011;20:527-533.

NEWSPAPER/MAGAZINE ARTICLE

As industry automates, adverse events continue to haunt caregivers.

Wetzel TG. Health Data Manage. 2011 Feb;19:86, 88, 90 passim.

STUDY

Adverse drug event rates in six community hospitals and the potential impact of computerized physician order entry for prevention.

Hug BL, Witkowski DJ, Sox CM, et al. J Gen Intern Med. 2010;25:31-38.

STUDY

Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data.

Nebeker JR, Yarnold PR, Soltysik RC, et al. Med Care. 2007;45(suppl 2):S81-S88.

STUDY

Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial.

Terrell KM, Perkins AJ, Hui SL, Callahan CM, Dexter PR, Miller DK. Ann Emerg Med. 2010;56:623-629.

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.

NEWSPAPER/MAGAZINE ARTICLE

Scanner beep only means the barcode has been scanned.

ISMP Medication Safety Alert! Acute Care Edition. June 30, 2011;16:1-2.

STUDY

Predictive value of alert triggers for identification of developing adverse drug events.

Moore C, Li J, Hung CC, Downs J, Nebeker JR. J Patient Saf. 2009;5:223-228.

COMMENTARY

Sick and Pregnant

El-Ibiary S. AHRQ WebM&M [serial online]. November 2008.

STUDY

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.

REVIEW

A review of current and emerging approaches to address failure-to-rescue.

Taenzer AH, Pyke JB, McGrath SP. Anesthesiology. 2011;115:421-431.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:1062-1065.

STUDY

Supratherapeutic dosing of acetaminophen among hospitalized patients.

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

COMMENTARY

A Mid-Summer Fog

Braddock CH. AHRQ WebM&M [serial online]. November 2008.

STUDY

Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy.

Waitman LR, Phillips IE, McCoy AB, et al. Jt Comm J Qual Patient Saf. 2011;37:326-332.

NEWSPAPER/MAGAZINE ARTICLE

Common cause analysis.

Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.

COMMENTARY classic

Fixing healthcare from the inside, today.

Spear SJ. Harv Bus Rev. September 2005;83:78-91.

STUDY

Defining the incidence of cardiorespiratory instability in patients in step-down units using an electronic integrated monitoring system.

Hravnak M, Edwards L, Clontz A, Valenta C, DeVita MA, Pinsky MR. Arch Intern Med. 2008;168:1300-1308.

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