AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (143)

•Diagnostic Errors (155)

•Identification Errors (94)

•Discontinuities, Gaps, and Hand-Off Problems (380)

•Fatigue and Sleep Deprivation (79)

•Medication Safety (1234)

•Medical Complications (381)

•Nonsurgical Procedural Complications (96)

•Surgical Complications (375)

•Transfusion Complications (17)

•Psychological and Social Complications (101)

Origin/Sponsor

•Africa (3)

•Asia (35)

•Australia and New Zealand (71)

•Central and South America (6)

•Europe (305)

•North America (2907)

Resource Types

•Clinical Guideline (7)

•Journal Article (2502)

•Legislation/Regulation (50)

•Meeting/Conference (30)

•Newsletter/Journal (12)

•Newspaper/Magazine Article (301)

•Press Release/Announcement (28)

•Special or Theme Issue (57)

•Tools/Toolkit (53)

•Web Resource (95)

•Grant (10)

Error Types

•Epidemiology of Errors and Adverse Events (780)

•Active Errors (564)

•Latent Errors (204)

•Near Miss (62)

Approach to Improving Safety

•Quality Improvement Strategies (775)

•Legal and Policy Approaches (275)

•Error Reporting and Analysis (830)

•Communication Improvement (865)

•Human Factors Engineering (477)

•Teamwork (289)

•Specialization of Care (263)

•Logistical Approaches (237)

•Culture of Safety (377)

•Technologic Approaches (714)

•Education and Training (617)

Clinical Areas

•Allied Health Services (8)

Target Audience
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Health Care Providers

•Allied Health Professionals (4)

•Clinical Technologists (24)

Setting of Care

•Psychiatric Facilities (15)

•Residential Facilities (60)

•Ambulatory Care (353)

•Outpatient Surgery (34)

•Patient Transport (28)

1 - 20 of 3373

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STUDY

Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit.

Abstoss KM, Shaw BE, Owens TA, Juno JL, Commiskey EL, Niedner MF. BMJ Qual Saf. 2011;914-922.

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

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

Utilising improvement science methods to optimise medication reconciliation.

White CM, Schoettker PJ, Conway PH, et al. BMJ Qual Saf. 2011;20:372-380.

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.

STUDY

National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors.

Pham JC, Story JL, Hicks RW, et al. J Emerg Med. 2011;40:485-492.

STUDY

Adverse drug event rates in six community hospitals and the potential impact of computerized physician order entry for prevention.

Hug BL, Witkowski DJ, Sox CM, et al. J Gen Intern Med. 2010;25:31-38.

STUDY

An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies.

Palchuk MB, Fang EA, Cygielnik JM, et al. J Am Med Inform Assoc. 2010;17:472-476.

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

Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases.

Bell CM, Brener SS, Gunraj N, et al. JAMA. 2011;306:840-847.

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.

NEWSPAPER/MAGAZINE ARTICLE

Another tragic parenteral nutrition compounding error.

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

STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

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

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.

STUDY

Critical drug–drug interactions for use in electronic health records systems with computerized physician order entry: review of leading approaches.

Classen DC, Phansalkar S, Bates DW. J Patient Saf. 2011;7:61-65.

STUDY

Effects of CPOE on provider cognitive workload: a randomized crossover trial.

Avansino J, Leu MG. Pediatrics. 2012;130:e547-e552.

STUDY

The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance.

Ahmed A, Chandra S, Herasevich V, Gajic O, Pickering BW. Crit Care Med. 2011;39:1626-1634.

SPECIAL OR THEME ISSUE

Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit.

Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(suppl 6):S83-S264.

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.

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