AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (39)

•Diagnostic Errors (120)

•Identification Errors (30)

•Discontinuities, Gaps, and Hand-Off Problems (144)

•Fatigue and Sleep Deprivation (62)

•Medication Safety (350)

•Medical Complications (47)

•Nonsurgical Procedural Complications (24)

•Surgical Complications (193)

•Transfusion Complications (3)

•Psychological and Social Complications (53)

Origin/Sponsor

•Asia (11)

•Australia and New Zealand (17)

•Central and South America (1)

•Europe (105)

•North America (1021)

Resource Types

•Audiovisual (12)

•Book/Report (27)

•Clinical Guideline (7)

•Journal Article (934)

•Legislation/Regulation (19)

•Meeting/Conference (4)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (131)

•Press Release/Announcement (13)

•Special or Theme Issue (11)

•Tools/Toolkit (15)

•Web Resource (21)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (230)

•Active Errors (172)

•Latent Errors (59)

•Near Miss (17)

Approach to Improving Safety

•Quality Improvement Strategies (297)

•Legal and Policy Approaches (102)

•Error Reporting and Analysis (332)

•Communication Improvement (288)

•Human Factors Engineering (99)

•Teamwork (84)

•Specialization of Care (55)

•Logistical Approaches (103)

•Culture of Safety (99)

•Technologic Approaches (194)

•Education and Training (260)

Clinical Areas

•Allied Health Services (3)

Target Audience
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Physicians

Setting of Care

•Hospitals (609)

•Psychiatric Facilities (2)

•Residential Facilities (6)

•Ambulatory Care (111)

•Outpatient Surgery (14)

•Patient Transport (3)

1 - 20 of 1199

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COMMENTARY

Preventing vincristine administration errors: does evidence support minibag infusions?

Schulmeister L. Clin J Oncol Nurs. 2006;10:271-273.

STUDY

Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes.

Alexander KP, Chen AY, Roe MT, et al; CRUSADE Investigators. JAMA. 2005;294:3108-3116.

FACT SHEET/FAQS

Oral Dosage Forms that Should Not Be Crushed.

Mitchell JF. Institute for Safe Medication Practices.

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

Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error.

Goodman EJ, Haas AJ, Kantor GS. Int J Obstet Anesth. 2006;15:63-67.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing vincristine administration errors.

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

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:556-557.

NEWSPAPER/MAGAZINE ARTICLE

Improving the safety of telephone or verbal orders.

PA-PSRS Patient Saf Advis. June 2006;3:1-5.

STUDY

Infant deaths associated with cough and cold medications—two states, 2005.

Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2007;56:1-4.

NEWSPAPER/MAGAZINE ARTICLE

Loud wake-up call: unlabeled containers lead to patient’s death.

ISMP Medication Safety Alert! Acute Care Edition. December 1, 2004;9:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Bringing surgeons down to earth.

Landro L. Wall Street Journal (Eastern edition). November 16, 2005:D1.

COMMENTARY

Medication safety: look-alike/sound-alike drugs in home care.

Friedman MM. Home Healthc Nurse. 2005;23:243-253.

BOOK/REPORT

Recommendations for Safe Use of Insulin in Hospitals.

Bethesda, MD: American Society of Health-System Pharmacists; 2006.

COMMENTARY

Improving safety throughout the medication use process in a neonatal intensive care unit.

Asdigha MN. Hosp Pharm. 2006;41:1067-1075.

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

Not again!

Berwick DM. BMJ. 2001;322:247-248.

TOOLKIT

Looking Collectively at Risk.

Pathways for Medication Safety Tool #2. Chicago, IL: American Hospital Association; 2003.

COMMENTARY

Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue].

Syed S, Paul JE, Hueftlein M, Kampf M, McLean RF. Can J Anaesth. 2006;53:586-590.

NEWSPAPER/MAGAZINE ARTICLE

Accuracy at every step: the challenge of medication reconciliation.

Institute for Healthcare Improvement Web site. March 20, 2006.

NEWSPAPER/MAGAZINE ARTICLE

IV potassium given epidurally: getting to the "route" of the problem.

ISMP Medication Safety Alert! Acute Care Edition. April 6, 2006;11:1-2.

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