AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (153)

•Diagnostic Errors (202)

•Identification Errors (105)

•Discontinuities, Gaps, and Hand-Off Problems (410)

•Fatigue and Sleep Deprivation (85)

•Medication Safety (1285)

•Medical Complications (404)

•Nonsurgical Procedural Complications (101)

•Surgical Complications (433)

•Transfusion Complications (17)

•Psychological and Social Complications (118)

Origin/Sponsor

•Australia and New Zealand (89)

•Central and South America (10)

•Europe (385)

•North America (3031)

Resource Types

•Audiovisual (30)

•Bibliography (2)

•Book/Report (194)

•Clinical Guideline (9)

•Journal Article (2669)

•Legislation/Regulation (54)

•Meeting/Conference (30)

•Newsletter/Journal (13)

•Newspaper/Magazine Article (308)

•Press Release/Announcement (30)

•Special or Theme Issue (59)

•Tools/Toolkit (57)

•Web Resource (107)

Error Types

•Epidemiology of Errors and Adverse Events (1069)

•Active Errors (609)

•Latent Errors (219)

•Near Miss (72)

Approach to Improving Safety

•Quality Improvement Strategies (851)

•Legal and Policy Approaches (306)

•Error Reporting and Analysis (973)

•Communication Improvement (920)

•Human Factors Engineering (499)

•Teamwork (292)

•Specialization of Care (259)

•Logistical Approaches (258)

•Culture of Safety (424)

•Technologic Approaches (635)

•Education and Training (779)

Clinical Areas

•Allied Health Services (10)

•Complementary and Alternative Medicine (1)

•Dentistry (5)

•Medicine (2377)

•Nursing (344)

•Pharmacy (502)

Target Audience
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Health Care Providers

•Allied Health Professionals (3)

•Clinical Technologists (38)

•Physicians (480)

•Nurses (422)

•Pharmacists (251)

Setting of Care

•Hospitals (2135)

•Psychiatric Facilities (18)

•Residential Facilities (85)

•Ambulatory Care (405)

•Outpatient Surgery (41)

•Patient Transport (32)

1 - 20 of 3605

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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.

REVIEW

Year in review: medication mishaps in the elderly.

Peron EP, Marcum ZA, Boyce R, Hanlon JT, Handler SM. Am J Geriatr Pharmacother. 2011;9:1-10.

STUDY

Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes.

Lapane KL, Hughes CM, Daiello LA, Cameron KA, Feinberg J. J Am Geriatr Soc. 2011;59:1238-1245.

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

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 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

classic

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.

STUDY

Medication errors involving oral chemotherapy.

Weingart SN, Toro J, Spencer J, et al. Cancer. 2010;116:2455-2464.

STUDY

Paramedic self-reported medication errors.

Vilke GM, Tornabene SV, Stepanski B, et al. Prehosp Emerg Care. 2007;11:80-84.

STUDY

Toward understanding errors in inpatient psychiatry: a qualitative inquiry.

Cullen SW, Nath SB, Marcus SC. Psychiatr Q. 2010;81:197-205.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:847-853.

REVIEW

"Tech-check-tech": a review of the evidence on its safety and benefits.

Adams AJ, Martin SJ, Stolpe SF. Am J Health Syst Pharm. 2011;68:1824-1833.

STUDY

The safety of hospital stroke care.

Holloway RG, Tuttle D, Baird T, Skelton WK. Neurology. 2007;68:550-555.

STUDY

Psychiatry morbidity and mortality rounds: implementation and impact.

Goldman S, Demaso DR, Kemler B. Acad Psychiatry. 2009;33:383-388.

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

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.

STUDY

Nursing home error and level of staff credentials.

Scott-Cawiezell J, Pepper GA, Madsen RW, Petroski G, Vogelsmeier A, Zellmer D. Clin Nurs Res. 2007;16:72-78.

STUDY

An in-depth analysis of medication errors in hospitalized patients with HIV.

Snyder AM, Klinker K, Orrick JJ, Janelle J, Winterstein AG. Ann Pharmacother. 2011;45:459-468.

STUDY

The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium.

Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog J; Pediatric Sedation Research Consortium. Anesth Analg. 2009;108:795-804.

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