AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (1)

•Diagnostic Errors (2)

•Identification Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (21)

•Medication Safety (61)

•Medical Complications (16)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (2)

•Psychological and Social Complications (3)

Origin/Sponsor

•Australia and New Zealand (5)

•North America (103)

Resource Types

•Book/Report (10)

•Clinical Guideline (1)

•Journal Article (96)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (9)

•Press Release/Announcement (1)

•Special or Theme Issue (2)

•Tools/Toolkit (3)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (40)

•Active Errors (15)

•Latent Errors (12)

•Near Miss (2)

Approach to Improving Safety

•Quality Improvement Strategies (26)

•Legal and Policy Approaches (16)

•Error Reporting and Analysis (37)

•Communication Improvement (33)

•Human Factors Engineering (10)

•Teamwork (6)

•Specialization of Care (6)

•Logistical Approaches (10)

•Culture of Safety (28)

•Technologic Approaches (21)

•Education and Training (18)

Clinical Areas

•Allied Health Services (2)

•Medicine (96)

•Nursing (21)

•Pharmacy (13)

Target Audience

•Health Care Providers (89)

•Health Care Executives and Administrators (100)

•Non-Health Care Professionals (33)

•Patients (8)

Setting of Care
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Residential Facilities

1 - 20 of 126

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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

Therapeutic errors involving adults in the community setting: nature, causes and outcomes.

Taylor DM, Robinson J, MacLeod D, MacBean CE, Braitberg G. Aust N Z J Public Health. 2009;33:388-394.

STUDY

Medication administration errors in nursing homes using an automated medication dispensing system.

van den Bemt PM, Idzinga JC, Robertz H, Kormelink DG, Pels N. J Am Med Inform Assoc. 2009;16:486-492.

STUDY

Quantification and classification of errors associated with hand-repackaging of medications in long-term care facilities in Germany.

Gerber A, Kohaupt I, Lauterbach KW, Buescher G, Stock S, Lungen M. Am J Geriatr Pharmacother. 2008;6:212-219.

STUDY

Medication errors during patient transitions into nursing homes: characteristics and association with patient harm.

Desai R, Williams CE, Greene SB, Pierson S, Hansen RA. Am J Geriatr Pharmacother. 2011;9:413-422.

STUDY

Medication discrepancies upon hospital to skilled nursing facility transitions.

Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. J Gen Intern Med. 2009;24:630-635.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2012.

COMMENTARY

Wrong Route for Nutrients

Scott-Cawiezell JR, AHRQ WebM&M [serial online]. July 2008.

STUDY

Medication administration errors in assisted living: scope, characteristics, and the importance of staff training.

Zimmerman S, Love K, Sloane PD, Cohen LW, Reed D, Carder PC; Center for Excellence in Assisted Living-University of North Carolina Collaborative. J Am Geriatr Soc. 2011;59:1060-1068.

STUDY

The influence of formulation and medicine delivery system on medication administration errors in care homes for older people.

Alldred DP, Standage C, Fletcher O, et al. BMJ Qual Saf. 2011;20:397-402.

STUDY

Nurse–physician communication in the long-term care setting: perceived barriers and impact on patient safety.

Tjia J, Mazor KM, Field T, Meterko V, Spenard A, Gurwitz JH. J Patient Saf. 2009;5:145-152.

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

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

Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality improvement opportunities.

Hansen RA, Cornell PY, Ryan PB, Williams CE, Pierson S, Greene SB. Pharmacoepidemiol Drug Saf. 2010;19:1087-1094.

STUDY

Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting.

Gurwitz JH, Field TS, Rochon P, et al. J Am Geriatr Soc. 2008;56:2225-2233.

STUDY

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.

STUDY

Addressing delays in medication administration for patients transferred from the hospital to the nursing home: a pilot quality improvement project.

Ward KT, Bates-Jensen B, Eslami MS, et al. Am J Geriatr Pharmacother. 2008;6:205-211.

STUDY

Organizational climate determinants of resident safety culture in nursing homes.

Arnetz JE, Zhdanova LS, Elsouhag D, Lichtenberg P, Luborsky MR, Arnetz BB. Gerontologist. 2011;51:739-749.

BOOK/REPORT

Trends in Nursing Home Deficiencies and Complaints.

Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2008. Report No. OEI-02-08-00140.

REVIEW

Nonhospital health care–associated hepatitis B and C virus transmission: United States, 1998-2008.

Thompson ND, Perz JF, Moorman AC, Holmberg SD. Ann Intern Med. 2009;150:33-39.

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