AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (135)

•Diagnostic Errors (111)

•Identification Errors (83)

•Discontinuities, Gaps, and Hand-Off Problems (535)

•Fatigue and Sleep Deprivation (117)

•Medication Safety (914)

•Medical Complications (402)

•Nonsurgical Procedural Complications (60)

•Surgical Complications (365)

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Error Types

•Epidemiology of Errors and Adverse Events (742)

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Approach to Improving Safety

•Quality Improvement Strategies (788)

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Clinical Areas

•Allied Health Services (5)

•Medicine (2297)

•Nursing (390)

•Pharmacy (365)

Target Audience

•Health Care Providers (2133)

•Health Care Executives and Administrators (2486)

•Non-Health Care Professionals (1064)

•Patients (292)

Setting of Care
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Hospitals

•General Hospitals (852)

•Children’s Hospitals (115)

•Specialty Hospitals (36)

1 - 20 of 3196

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COMMENTARY

Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge.

Rodehaver C. Jt Comm J Qual Patient Saf. 2005;31:406-413.

STUDY

Implementation of an electronic system for medication reconciliation.

Kramer JS, Hopkins PJ, Rosendale JC, et al. Am J Health Syst Pharm. 2007;64:404-422.

NEWSPAPER/MAGAZINE ARTICLE

Survey results: community liaison programs to decrease hospital readmissions.

ISMP Medication Safey Alert! Acute Care Edition. March 7, 2013;18:1-3.

STUDY

Medication reconciliation for reducing drug-discrepancy adverse events.

Boockvar KS, Carlson Lacorte H, Giambanco V, Fridman B, Siu A. Am J Geriatr Pharmacother. 2006;4:236-243.

STUDY

"Did I do as best as the system would let me?" Healthcare professional views on hospital to home care transitions.

Davis MM, Devoe M, Kansagara D, Nicolaidis C, Englander H. J Gen Intern Med. 2012;27:1649-1656.

NEWSPAPER/MAGAZINE ARTICLE

JCAHO tightens leash on medication reconciliation.

Perry LE. Drug Topics: Health-System Edition. March 20, 2006.

COMMENTARY

Citrate Mix-Up

Weber RJ. AHRQ WebM&M [serial online]. May 2006.

COMMENTARY

Developing a medication patient safety program, part 2: process and implementation.

Mark SM, Weber RJ. Hosp Pharm. 2007;42:249–254.

COMMENTARY

Improving care transitions: current practice and future opportunities for pharmacists.

American College of Clinical Pharmacy, Hume AL, Kirwin J, et al. Pharmacotherapy. 2012;32:e326-e337.

COMMENTARY

Medication bar coding: to scan or not to scan?

Galvin L, McBeth S, Hasdorff C, Tillson M, Thomas S. Comput Inform Nurs. 2007;25:86-92.

STUDY

Effects of an automatic drug dispensing system on medication adverse event occurrences and cost containment at SAMSO.

Dib JG, Abdulmohsin SA, Farooki MU, et al. Hosp Pharm. 2006;41:1180-1184.

NEWSPAPER/MAGAZINE ARTICLE

Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives.

ISMP Medication Safety Alert! Acute Care Edition. February 9, 2012;17:1-4.

NEWSPAPER/MAGAZINE ARTICLE

JCAHO views medication reconciliation as adverse-event prevention.

Thompson CA. Am J Health Syst Pharm. 2005;62:1528-1532.

NEWSPAPER/MAGAZINE ARTICLE

Improving the safety of telephone or verbal orders.

PA-PSRS Patient Saf Advis. June 2006;3:1-5.

NEWSPAPER/MAGAZINE ARTICLE

Results of our survey on drug storage, stability, compatibility, and beyond use dating.

ISMP Medication Safety Alert! Acute Care Edition. March 22, 2012;17:1-4.

STUDY

The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use.

Page RL 2nd, Ruscin JM. Am J Geriatr Pharmacother. 2006;4:297-305.

STUDY

Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods.

Payne CE, Stein JM, Leong T, Dressler DD. BMJ Qual Saf. 2012;21:925-932.

STUDY

Reconciling medications at admission: safe practice recommendations and implementation strategies.

Rogers G, Alper E, Brunelle D, et al. Jt Comm J Qual Patient Saf. 2006;32:37-50.

REVIEW

Clinical dilemmas and a review of strategies to manage drug shortages.

Rider AE, Templet DJ, Daley MJ, Shuman C, Smith LV. J Pharm Pract. 2013 Apr 3; [Epub ahead of print].

STUDY

Effectiveness of a pharmacist–nurse intervention on resolving medication discrepancies for patients transitioning from hospital to home health care.

Setter SM, Corbett CF, Neumiller JJ, Gates BJ, Sclar DA, Sonnett TE. Am J Health Syst Pharm. 2009;66:2027-2031.

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