AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (61)

•Diagnostic Errors (14)

•Identification Errors (4)

•Discontinuities, Gaps, and Hand-Off Problems (44)

•Fatigue and Sleep Deprivation (14)

•Medication Safety (123)

•Medical Complications (94)

•Nonsurgical Procedural Complications (10)

•Surgical Complications (17)

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•Psychological and Social Complications (3)

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•Clinical Guideline (1)

•Journal Article (350)

•Meeting/Conference (1)

•Newspaper/Magazine Article (22)

•Press Release/Announcement (4)

•Special or Theme Issue (4)

•Tools/Toolkit (1)

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Error Types

•Epidemiology of Errors and Adverse Events (131)

•Active Errors (68)

•Latent Errors (25)

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Approach to Improving Safety

•Quality Improvement Strategies (96)

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Clinical Areas

•Medicine (371)

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Target Audience

•Health Care Providers (270)

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Setting of Care
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Intensive Care Units

1 - 20 of 392

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STUDY

Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children.

Uppal N, Yasseen B, Seto W, Parshuram CS. CMAJ. 2011;183:E246-E248.

STUDY

A comparison of voluntarily reported medication errors in intensive care and general care units.

Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.

STUDY

Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration.

Yamamoto L, Kanemori J. Am J Emerg Med. 2010;28:588-592.

STUDY

Impact of computerized orders for pediatric continuous drug infusions on detecting infusion pump programming errors: a simulated study.

Sowan AK, Gaffoor MI, Soeken K, Johantgen ME, Vaidya VU. J Pediatr Nurs. 2010;25:108-118.

NEWSPAPER/MAGAZINE ARTICLE

Another tragic parenteral nutrition compounding error.

ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.

STUDY

Computerized order entry with limited decision support to prevent prescription errors in a PICU.

Kadmon G, Bron-Harlev E, Nahum E, Schiller O, Haski G, Shonfeld T. Pediatrics. 2009;124:945-950.

STUDY

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.

STUDY

Risk of adverse drug events in neonates treated with opioids and the effect of a bar-code–assisted medication administration system.

Morriss FH, Jr, Abramowitz PW, Nelson SP, Milavetz G, Michael SL, Gordon SN. Am J Health Syst Pharm. 2011;68:57-62.

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

Baby's death spotlights safety risks linked to computerized systems.

Graham J, Dizikes C. Chicago Tribune. June 27, 2011.

STUDY

Errors in administration of parenteral drugs in intensive care units: multinational prospective study.

Valentin A, Capuzzo M, Guidet B, et al; Research Group on Quality Improvement of the European Society of Intensive Care Medicine (ESICM); Sentinel Events Evaluation (SEE) Study Investigators. BMJ. 2009;338:b814.

STUDY

Medical errors recovered by critical care nurses.

Dykes PC, Rothschild JM, Hurley AC. J Nurs Adm. 2010;40:241-246.

MEETING/CONFERENCE PROCEEDINGS

Safety in the NICU: preventing medical errors.

Stokowski LA. Highlights of the National Association of Neonatal Nurses 22nd Annual Conference [Medscape.com]. March 8, 2007.

STUDY

Pediatric safety incidents from an intensive care reporting system.

Skapik JL, Pronovost PJ, Miller MR, Thompson DA, Wu AW. J Patient Saf. 2009;5:95-101.

STUDY

Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.

Kaplan LJ, Maerz LL, Schuster K, et al. J Trauma. 2009;67:173-179.

STUDY

Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study.

Morriss FH Jr, Abramowitz PW, Nelson SP, et al. J Pediatr. 2009;197:678-685.

STUDY

Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II.

Garrouste-Orgeas M, Timsit JF, Vesin A, et al; OUTCOMEREA Study Group. Am J Respir Crit Care Med. 2010:181:134-142.

PRESS RELEASE/ANNOUNCEMENT

Serious medication errors from intravenous administration of nimodipine oral capsules.

MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; August 2, 2010.

STUDY

Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units.

De Giorgi I, Fonzo-Christe C, Cingria L, et al. Int J Qual Health Care. 2010;22:170-178.

STUDY

Variability in the concentrations of intravenous drug infusions prepared in a critical care unit.

Wheeler DW, Degnan BA, Sehmi JS, et al. Intensive Care Med. 2008;34:1441-1447.

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