AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (112)

•Diagnostic Errors (152)

•Identification Errors (78)

•Discontinuities, Gaps, and Hand-Off Problems (245)

•Fatigue and Sleep Deprivation (39)

•Medication Safety (743)

•Medical Complications (237)

•Nonsurgical Procedural Complications (74)

•Surgical Complications (298)

•Transfusion Complications (12)

•Psychological and Social Complications (58)

Origin/Sponsor

•Africa (3)

•Asia (37)

•Australia and New Zealand (77)

•Central and South America (8)

•Europe (328)

•North America (1522)

Resource Types

•Audiovisual (7)

•Award (6)

•Book/Report (71)

•Clinical Guideline (3)

•Journal Article (1647)

•Legislation/Regulation (28)

•Meeting/Conference (14)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (117)

•Press Release/Announcement (29)

•Special or Theme Issue (23)

•Tools/Toolkit (25)

•Web Resource (51)

•Grant (8)

Error Types

•Epidemiology of Errors and Adverse Events (561)

•Active Errors (616)

•Latent Errors (165)

•Near Miss (59)

Approach to Improving Safety

•Quality Improvement Strategies (518)

•Legal and Policy Approaches (148)

•Error Reporting and Analysis (552)

•Communication Improvement (571)

•Human Factors Engineering (356)

•Teamwork (184)

•Specialization of Care (123)

•Logistical Approaches (135)

•Culture of Safety (207)

•Technologic Approaches (386)

•Education and Training (387)

Clinical Areas

•Allied Health Services (10)

•Complementary and Alternative Medicine (1)

Target Audience
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Health Care Providers

•Allied Health Professionals (3)

•Clinical Technologists (12)

Setting of Care

•Psychiatric Facilities (13)

•Residential Facilities (38)

•Ambulatory Care (298)

•Outpatient Surgery (25)

•Patient Transport (22)

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STUDY

Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model.

White RE, Trbovich PL, Easty AC, Savage P, Trip K, Hyland S. Qual Saf Health Care. 2010;19:562-567.

NEWSPAPER/MAGAZINE ARTICLE

Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.

ISMP Medication Safety Alert! Acute Care Edition. August 26, 2010;15:1-3.

COMMENTARY

Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine?

Reddy GK, Brown B, Nanda A. Clin Neurol Neurosurg. 2011;113:68-71.

STUDY

Chemotherapy patients' perceptions of drug administration safety.

Schwappach DLB, Wernli M. J Clin Oncol. 2010;28:2896-2901.

STUDY

Computerized physician order entry of injectable antineoplastic drugs: an epidemiologic study of prescribing medication errors.

Nerich V, Limat S, Demarchi M, et al. Int J Med Inform. 2010;79:699-706.

REVIEW

Medication errors in chemotherapy: incidence, types and involvement of patients in prevention. A review of the literature.

Schwappach DLB, Wernli M. Eur J Cancer Care (Engl). 2009;19:285-292.

ORGANIZATIONAL POLICY/GUIDELINES

American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards.

Jacobson JO, Polovich M, McNiff KK, et al; American Society of Clinical Oncology; Oncology Nursing Society. Oncol Nurs Forum. 2009;36:651-658.

STUDY

Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety.

Collins CM, Elsaid KA. Int J Qual Health Care. 2011;23:36-43.

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

The use of human factors methods to identify and mitigate safety issues in radiation therapy.

Chan AJ, Islam MK, Rosewall T, Jaffray DA, Easty AC, Cafazzo JA. Radiother Oncol. 2010;97:596-600.

STUDY

Electronic prescribing in an ambulatory care setting: a cluster randomized trial.

Dainty KN, Adhikari NK, Kiss A, Quan S, Zwarenstein M. J Eval Clin Pract. 2012;18:761-767.

STUDY

Impact of implementing alerts about medication black-box warnings in electronic health records.

Yu DT, Seger DL, Lasser KE, et al. Pharmacoepidemiol Drug Saf. 2011;20:192-202.

MEASUREMENT TOOL/INDICATOR

2012 ISMP International Medication Safety Self Assessment for Oncology.

Institute for Safe Medication Practices and Institute for Safe Medication Practices Canada.

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.

STUDY

Medication errors involving oral chemotherapy.

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

NEWSPAPER/MAGAZINE ARTICLE

Preventing catheter/tubing misconnections: much needed help is on the way.

ISMP Medication Safety Alert! Acute Care Edition. July 15, 2010;15:1-2.

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.

COMMENTARY

Dealing honestly with an honest mistake.

Liang NL, Herring ME, Bush RL. J Vasc Surg. 2010;51:494-495.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010:45;352-355.

STUDY

Impact of a comprehensive safety initiative on patient-controlled analgesia errors.

Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.

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