AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (146)

•Diagnostic Errors (95)

•Identification Errors (69)

•Discontinuities, Gaps, and Hand-Off Problems (230)

•Fatigue and Sleep Deprivation (41)

•Medication Safety (713)

•Medical Complications (252)

•Nonsurgical Procedural Complications (68)

•Surgical Complications (264)

•Transfusion Complications (8)

•Psychological and Social Complications (71)

Origin/Sponsor

•Asia (5)

•Australia and New Zealand (15)

•Central and South America (1)

•Europe (77)

•North America (2111)

Resource Types

•Clinical Guideline (5)

•Journal Article (1509)

•Legislation/Regulation (40)

•Meeting/Conference (26)

•Newsletter/Journal (11)

•Newspaper/Magazine Article (232)

•Press Release/Announcement (28)

•Special or Theme Issue (42)

•Tools/Toolkit (40)

•Web Resource (78)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (446)

•Active Errors (380)

•Latent Errors (133)

•Near Miss (42)

Approach to Improving Safety

•Quality Improvement Strategies (530)

•Legal and Policy Approaches (214)

•Error Reporting and Analysis (537)

•Communication Improvement (595)

•Human Factors Engineering (465)

•Teamwork (180)

•Specialization of Care (139)

•Logistical Approaches (137)

•Culture of Safety (278)

•Technologic Approaches (413)

•Education and Training (429)

Clinical Areas

•Allied Health Services (6)

Target Audience
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Health Care Providers

•Clinical Technologists (10)

Setting of Care

•Psychiatric Facilities (11)

•Residential Facilities (45)

•Ambulatory Care (257)

•Outpatient Surgery (26)

•Patient Transport (17)

1 - 20 of 2219

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COMMENTARY

ISMP medication error report analysis.

Cohen MC. Hosp Pharm. 2009;44:374-378.

NEWSPAPER/MAGAZINE ARTICLE

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.

PRESS RELEASE/ANNOUNCEMENT

Information for healthcare professionals: risk of transmission of blood-borne pathogens from shared use of insulin pens.

FDA Alert [US Food and Drug Administration Web site]. March 19, 2009.

COMMENTARY

Addressing safety concerns about U-500 insulin in a hospital setting.

Samaan KH, Dahlke M, Stover J. Am J Health Syst Pharm. 2011;68:63-68.

SPECIAL OR THEME ISSUE

Patient safety and quality in the pediatric intensive care unit.

Pediatr Crit Care Med. 2007;8(suppl):S1-S43.

NEWSPAPER/MAGAZINE ARTICLE

Shakespeare was on target—don't be a borrower or lender.

ISMP Medication Safety Alert! Acute Care Edition. November 19, 2009;14:1-3.

PRESS RELEASE/ANNOUNCEMENT

Potentially fatal errors with GDH-PQQ [glucose dehydrogenase pyrroloquinoline quinone] glucose monitoring technology.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 13, 2009.

AUDIOVISUAL PRESENTATION

Preventing Medical Errors.

Food and Drug Administration (FDA) Patient Safety News. Show #79. September 2008.

STUDY

Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers.

Spiller HA, Borys DJ, Ryan ML, Sawyer TS, Wilson BL. Ann Pharmacother. 2011;45:17-22.

COMMENTARY

Practice advisory on anesthetic care for magnetic resonance imaging: a report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging.

Anesthesiology. 2009;110:459-479.

STUDY

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.

STUDY

Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit.

Berenholtz SM, Pham JC, Thompson DA, et al. Infect Control Hosp Epidemiol. 2011;32:305-314.

NEWSPAPER/MAGAZINE ARTICLE

Oral syringes: a crucial and economical risk-reduction strategy that has not been fully utilized.

ISMP Medication Safety Alert! Acute Care Edition. October 22, 2009;14:1-3.

NEWSPAPER/MAGAZINE ARTICLE

An overlooked condition.

Nicholas L. Modern Healthc. November 14, 2005;35:24.

NEWSPAPER/MAGAZINE ARTICLE

Common cause analysis.

Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.

PRESS RELEASE/ANNOUNCEMENT

Parenteral Maltose/Parenteral Galactose/Oral Xylose-Containing Products.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; May 21, 2009.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors occurring with the use of bar-code administration technology.

PA-PSRS Patient Saf Advis. December 2008;5:122-126.

STUDY

Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.

Tham E, Calmes HM, Poppy A, et al. Pediatrics. 2011;128:e438-e445.

NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

ISMP Medication Safety Alert! Acute Care Edition. May 3, 2007;12:1-2.

NEWSPAPER/MAGAZINE ARTICLE

A clinical reminder about the safe use of insulin vials.

ISMP Medication Safety Alert! Acute Care Edition. February 21, 2013;18:1-3.

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