AHRQ Patient Safety Network

The Collection > Physicians

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Safety Target

•Device-related Complications (36)

•Diagnostic Errors (82)

•Identification Errors (29)

•Discontinuities, Gaps, and Hand-Off Problems (111)

•Fatigue and Sleep Deprivation (41)

•Medication Safety (326)

•Medical Complications (31)

•Nonsurgical Procedural Complications (17)

•Surgical Complications (139)

•Transfusion Complications (2)

•Psychological and Social Complications (54)

Origin/Sponsor

•Asia (14)

•Australia and New Zealand (25)

•Central and South America (1)

Resource Types

•Clinical Guideline (7)

•Journal Article (718)

•Legislation/Regulation (14)

•Meeting/Conference (1)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (91)

•Press Release/Announcement (11)

•Special or Theme Issue (4)

•Tools/Toolkit (15)

•Web Resource (14)

Error Types

•Epidemiology of Errors and Adverse Events (186)

•Active Errors (133)

•Latent Errors (64)

•Near Miss (15)

Approach to Improving Safety

•Quality Improvement Strategies (267)

•Legal and Policy Approaches (64)

•Error Reporting and Analysis (266)

•Communication Improvement (253)

•Human Factors Engineering (79)

•Teamwork (63)

•Specialization of Care (41)

•Logistical Approaches (60)

•Culture of Safety (60)

•Technologic Approaches (153)

•Education and Training (149)

Clinical Areas

•Allied Health Services (4)

Target Audience
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Physicians

Setting of Care

•Hospitals (453)

•Psychiatric Facilities (2)

•Residential Facilities (6)

•Ambulatory Care (101)

•Outpatient Surgery (10)

•Patient Transport (3)

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COMMENTARY

Citrate Mix-Up

Weber RJ. AHRQ WebM&M [serial online]. May 2006.

NEWSPAPER/MAGAZINE ARTICLE

Promethazine conundrum: IV can hurt more than IM injection!

ISMP Medication Safety Alert! Acute Care Edition. November 2, 2006;11:1-3.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:725-728.

COMMENTARY

Crossed Coverage

Kayser SR. AHRQ WebM&M [serial online]. February 2007.

COMMENTARY

Right? Left? Neither!

Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.

NEWSPAPER/MAGAZINE ARTICLE

Safety in ASCs: putting patients first.

Dix K. Today's Surgicenter. December 1, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Tablet splitting: Do it only if you "half" to, and then do it safely.

ISMP Medication Safety Alert! Acute Care Edition. May 18, 2006;11:1-2.

COMMENTARY

Getting to the Root of the Matter

Flanders SA, Saint S. AHRQ WebM&M [serial online]. June 2005.

COMMENTARY

Miscalculated Risk

Strassels SA. AHRQ WebM&M [serial online]. August 2006.

COMMENTARY

A Troubling Amine

Flynn EA. AHRQ WebM&M [serial online]. September 2006.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing vincristine administration errors.

The Joint Commission. Sentinel Event Alert. July 14, 2005;(34):1-3.

STUDY

Medication errors in intravenous drug preparation and administration: a multicentre audit in the UK, Germany and France.

Cousins DH, Sabatier B, Begue D, Schmitt C, Hoppe-Tichy T. Qual Saf Health Care. 2005;14:190-195.

STUDY

Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin.

Donihi AC, DiNardo MM, DeVita MA, Korytkowski MT. Qual Saf Health Care. 2006;15:89-91.

AUDIOVISUAL

Preventing fatal heparin overdoses.

Food and Drug Administration (FDA) Patient Safety News. Show #58. December 2006.

FACT SHEET/FAQS

Oral Dosage Forms that Should Not Be Crushed.

Mitchell JF. Institute for Safe Medication Practices.

STUDY

Emergency department visits for outpatient adverse drug events: demonstration for a national surveillance system.

Budnitz DS, Pollock DA, Mendelsohn AB, Weidenbach KN, McDonald AK, Annest JL. Ann Emerg Med. 2005;45:197-206.

PRESS RELEASE/ANNOUNCEMENT

Mix-up (wrong route of administration) of bladder irrigation with intravenous (IV) infusions.

VA National Center for Patient Safety. Washington, DC: VA Central Office; April 6, 2006. Patient Safety Alert AL06-012.

STUDY

The importance of establishing regimen concordance in preventing medication errors in anticoagulant care.

Schillinger D, Wang F, Rodriguez M, Bindman A, Machtinger EL. J Health Comm. 2006;11:555-567.

NEWSPAPER/MAGAZINE ARTICLE

When I follow up, I don't give up.

Roy PJ. Med Econ. 2006 Aug 4;83:68-69.

COMMENTARY

Patient safety in the dialysis facility.

Kliger AS. Blood Purif. 2006;24:19-21.

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