AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (46)

•Diagnostic Errors (35)

•Identification Errors (31)

•Discontinuities, Gaps, and Hand-Off Problems (109)

•Fatigue and Sleep Deprivation (23)

•Medication Safety (522)

•Medical Complications (139)

•Nonsurgical Procedural Complications (20)

•Surgical Complications (68)

•Transfusion Complications (9)

•Psychological and Social Complications (20)

Origin/Sponsor

•Australia and New Zealand (32)

•Central and South America (5)

•Europe (164)

•North America (703)

Resource Types

•Audiovisual (4)

•Book/Report (56)

•Clinical Guideline (1)

•Journal Article (776)

•Legislation/Regulation (8)

•Meeting/Conference (1)

•Newspaper/Magazine Article (82)

•Press Release/Announcement (2)

•Special or Theme Issue (2)

•Tools/Toolkit (4)

•Web Resource (10)

Error Types

•Epidemiology of Errors and Adverse Events (692)

•Active Errors (133)

•Latent Errors (54)

•Near Miss (22)

Approach to Improving Safety

•Quality Improvement Strategies (176)

•Legal and Policy Approaches (62)

•Error Reporting and Analysis (414)

•Communication Improvement (174)

•Human Factors Engineering (93)

•Teamwork (28)

•Specialization of Care (76)

•Logistical Approaches (79)

•Culture of Safety (85)

•Technologic Approaches (196)

•Education and Training (123)

Clinical Areas

•Allied Health Services (1)

•Medicine (662)

•Nursing (88)

•Pharmacy (192)

Target Audience

•Health Care Providers (625)

•Health Care Executives and Administrators (749)

•Non-Health Care Professionals (302)

•Patients (50)

Setting of Care
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Hospitals

•General Hospitals (125)

•Children’s Hospitals (15)

•Specialty Hospitals (15)

1 - 20 of 950

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NEWSPAPER/MAGAZINE ARTICLE

Medication errors: when pharmacy is closed.

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

STUDY

Potential medication errors associated with computer prescriber order entry.

Villamañán E, Larrubia Y, Ruano M, et al. Int J Clin Pharm. 2013 Apr 11; [Epub ahead of print].

STUDY

The effect of medication reconciliation in elderly patients at hospital discharge.

Midlöv P, Bahrani L, Seyfali M, Höglund P, Rickhag E, Eriksson T. Int J Clin Pharm. 2012;34:113-119.

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

Impact of vendor computerized physician order entry in community hospitals.

Leung AA, Keohane C, Amato M, et al. J Gen Intern Med. 2012;27:801-807.

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

A cross-sectional study on the relationship between utilization of root cause analysis and patient safety at 139 Department of Veterans Affairs medical centers.

Percarpio KB, Watts V. Jt Comm J Qual Patient Saf. 2013;39:32-37.

STUDY

Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents.

Davies EC, Green CF, Mottram DR, Pirmohamed M. Br J Clin Pharmacol. 2010;70:102-108.

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.

STUDY

The safety of electronic prescribing: manifestations, mechanisms, and rates of system-related errors associated with two commercial systems in hospitals.

Westbrook JI, Baysari MT, Li L, Burke R, Richardson KL, Day RO. J Am Med Inform Assoc. 2013 May 30; [Epub ahead of print].

STUDY

Medication errors involving patient-controlled analgesia.

Hicks RW, Sikirica V, Nelson W, Schein JR, Cousins DD. Am J Health Syst Pharm. 2008;65:429-440.

STUDY

Prescribing discrepancies likely to cause adverse drug events after patient transfer.

Boockvar KS, Liu S, Goldstein N, Nebeker J, Siu A, Fried T. Qual Saf Health Care. 2009;18:32-36.

STUDY

Nursing perception of the impact of medication carts on patient safety and ergonomics in a teaching health care center.

Rochais É, Atkinson S, Bussières JF. J Pharm Pract. 2013;26:131-137.

NEWSPAPER/MAGAZINE ARTICLE

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

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

COMMENTARY

Eliminating adverse drug events at Ascension Health.

Butler K, Mollo P, Gale JL, Rapp DA. Jt Comm J Qual Patient Saf. 2007;33:527-536.

REVIEW

Reduction in medication errors in hospitals due to adoption of computerized provider order entry systems.

Radley DC, Wasserman MR, Olsho LE, Shoemaker SJ, Spranca MD, Bradshaw B. J Am Med Inform Assoc. 2013;20:470-476.

STUDY

Retrospective analysis of medication incidents reported using an on-line reporting system.

Ashcroft DM, Cooke J. Pharm World Sci. 2006;28:359-65.

NEWSPAPER/MAGAZINE ARTICLE

Fluorouracil error ends tragically, but application of lessons learned will save lives.

ISMP Medication Safety Alert! Acute Care Edition. September 20, 2007;12:1-3.

COMMENTARY

Improving care transitions: optimizing medication reconciliation.

American Pharmacists Association, American Society of Health-System Pharmacists. J Am Pharm Assoc. 2012;52:e43-e52.

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