AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (138)

•Diagnostic Errors (91)

•Identification Errors (72)

•Discontinuities, Gaps, and Hand-Off Problems (343)

•Fatigue and Sleep Deprivation (75)

•Medication Safety (940)

•Medical Complications (383)

•Nonsurgical Procedural Complications (47)

•Surgical Complications (265)

•Transfusion Complications (18)

•Psychological and Social Complications (81)

Origin/Sponsor

•Australia and New Zealand (54)

•Central and South America (7)

•Europe (228)

•North America (2350)

Resource Types

•Audiovisual (35)

•Book/Report (145)

•Clinical Guideline (3)

•Journal Article (1940)

•Legislation/Regulation (32)

•Meeting/Conference (13)

•Newspaper/Magazine Article (410)

•Press Release/Announcement (8)

•Special or Theme Issue (19)

•Tools/Toolkit (29)

•Web Resource (46)

Error Types

•Epidemiology of Errors and Adverse Events (1027)

•Active Errors (377)

•Latent Errors (193)

•Near Miss (55)

Approach to Improving Safety

•Quality Improvement Strategies (627)

•Legal and Policy Approaches (284)

•Error Reporting and Analysis (975)

•Communication Improvement (550)

•Human Factors Engineering (290)

•Teamwork (141)

•Specialization of Care (226)

•Logistical Approaches (235)

•Culture of Safety (354)

•Technologic Approaches (464)

•Education and Training (449)

Clinical Areas

•Allied Health Services (2)

•Medicine (1908)

•Nursing (281)

•Pharmacy (351)

Target Audience

•Health Care Providers (1664)

•Health Care Executives and Administrators (2054)

•Non-Health Care Professionals (874)

•Patients (271)

Setting of Care
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Hospitals

•General Hospitals (565)

•Children’s Hospitals (82)

•Specialty Hospitals (34)

1 - 20 of 2699

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TOOLS/TOOLKIT

Introduction to Trigger Tools for Identifying Adverse Events.

Institute for Healthcare Improvement.

STUDY

Provider and pharmacist responses to warfarin drug–drug interaction alerts: a study of healthcare downstream of CPOE alerts.

Miller AM, Boro MS, Korman NE, Davoren JB. J Am Med Inform Assoc. 2011;18(suppl 1):i45-i50.

STUDY

Medication errors and response bias: the tip of the iceberg.

Bar-Oz B, Goldman M, Lahat E, et al. Isr Med Assoc J. 2008;10:771-774.

STUDY

Rate, causes and reporting of medication errors in Jordan: nurses' perspectives.

Mrayyan MT, Shishani K, Al-Faouri I. J Nurs Manag. Sep 2007;15:659-670.

STUDY

classic

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

Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance.

Classen DC, Jaser L, Budnitz DS. Jt Comm J Qual Patient Saf. 2010;36:12-21, AP1-AP9.

STUDY

Predictors of medication errors among elderly hospital patients.

Picone DM, Titler MG, Dochterman J, et al. Am J Med Qual. 2008;23:115-127.

STUDY

Anticoagulation-associated adverse drug events.

Piazza G, Nguyen TN, Cios D, et al. Am J Med. 2011;124:1136-1142.

STUDY

Pediatric medication errors in the postanesthesia care unit: analysis of MEDMARX data.

Payne CH, Smith CR, Newkirk LE, Hicks RW. AORN J. 2007;85:731-740.

MEASUREMENT TOOL/INDICATOR

2005 ISMP Medication Safety Self Assessment® for Antithrombotic Therapy in Hospitals.

Huntingdon Valley, PA: Institute for Safe Medication Practices; 2005.

NEWSPAPER/MAGAZINE ARTICLE

USP initiatives for the safe use of medical gases.

Zaidi K, Curry PD Jr, Becker SC. Pharmaceutical Technology. November 2, 2005;29:102-103.

STUDY

Antecedents of severe and nonsevere medication errors.

Chang YK, Mark BA. J Nurs Scholarsh. 2009;41:70-78.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: when pharmacy is closed.

PA-PSRS Patient Saf Advis. March 2012;9:11-17.

NEWSPAPER/MAGAZINE ARTICLE

Technological methods used to prevent errors aren't infallible.

Santell JP. Mater Manage Health Care. December 19, 2006;15:26-28, 30.

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.

STUDY

Inter-rater reliability of a classification system for hospital adverse drug event reports.

Haynes K, Hennessy S, Morales KH, et al. Clin Pharmacol Ther. 2008;83:485-488.

STUDY

Drug errors and related interventions reported by United States clinical pharmacists: The American College of Clinical Pharmacy Practice-Based Research Network medication error detection, amelioration and prevention study.

Kuo GM, Touchette DR, Marinac JS; American College of Clinical Pharmacy Practice-Based Research Network Collaborative. Pharmacotherapy. 2013;33:253-265.

STUDY

Supratherapeutic dosing of acetaminophen among hospitalized patients.

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

NEWSPAPER/MAGAZINE ARTICLE

Common cause analysis.

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

NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

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

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