AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (29)

•Diagnostic Errors (22)

•Identification Errors (15)

•Discontinuities, Gaps, and Hand-Off Problems (65)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (273)

•Medical Complications (24)

•Nonsurgical Procedural Complications (11)

•Surgical Complications (71)

•Transfusion Complications (2)

•Psychological and Social Complications (4)

Origin/Sponsor

•Asia (9)

•Australia and New Zealand (17)

•Central and South America (1)

Resource Types

•Clinical Guideline (5)

•Journal Article (404)

•Legislation/Regulation (12)

•Meeting/Conference (1)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (60)

•Press Release/Announcement (9)

•Special or Theme Issue (3)

•Tools/Toolkit (12)

•Web Resource (10)

Error Types

•Epidemiology of Errors and Adverse Events (100)

•Active Errors (59)

•Latent Errors (30)

•Near Miss (9)

Approach to Improving Safety

•Quality Improvement Strategies (174)

•Legal and Policy Approaches (19)

•Error Reporting and Analysis (125)

•Communication Improvement (141)

•Human Factors Engineering (59)

•Teamwork (49)

•Specialization of Care (38)

•Logistical Approaches (20)

•Culture of Safety (35)

•Technologic Approaches (101)

•Education and Training (85)

Clinical Areas

•Allied Health Services (2)

•Medicine (380)

•Nursing (46)

•Pharmacy (116)

Target Audience
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Physicians

Setting of Care

•Hospitals (300)

•Psychiatric Facilities (1)

•Residential Facilities (3)

•Ambulatory Care (55)

•Outpatient Surgery (4)

•Patient Transport (2)

1 - 20 of 530

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REVIEW

Adverse events associated with sedatives, analgesics, and other drugs that provide patient comfort in the intensive care unit.

Riker RR, Fraser GL. Pharmacotherapy. 2005;25:8S-18S.

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

Getting to the Root of the Matter

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

PRESS RELEASE/ANNOUNCEMENT

Heparin sodium injection 10,000 units/mL, and HEP-LOCK U/P 10 units/mL medication errors.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 6, 2007.

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.

AUDIOVISUAL

Preventing fatal heparin overdoses.

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

PRESS RELEASE/ANNOUNCEMENT

FDA public health notification: MRI-caused injuries in patients with implanted neurological stimulators.

Schultz DG. Rockville, MD: Center for Devices and Radiological Health, Food and Drug Administration; May 10, 2005.

PRESS RELEASE/ANNOUNCEMENT

Safety warnings regarding use of fentanyl transdermal (skin) patches.

FDA Public Health Advisory. Silver Spring, MD: US Food and Drug Administration; December 21, 2007.

TOOLKIT

ISMP and FDA campaign to eliminate use of error-prone abbreviations.

Huntington Valley, PA: Institute for Safe Medication Practices.

MEETING/CONFERENCE PROCEEDINGS

Public Meeting on Improving Patient Safety by Enhancing the Container Labeling for Parenteral Infusion Drug Products.

US Food and Drug Administration, Center for Drug Evaluation and Research. January 11, 2007.

STUDY

Potentially inappropriate prescribing in elderly veterans: are we using the wrong drug, wrong dose, or wrong duration?

Pugh MJ, Fincke BG, Bierman AS, et al. J Am Geriatr Soc. 2005;53:1282-1289.

STUDY

Risk factors for adverse drug events: a 10-year analysis.

Evans RS, Lloyd JF, Stoddard GJ, Nebeker JR, Samore MH. Ann Pharmacother. 2005;39:1161-1168.

TOOLKIT

Checklist/Action Plan for the Management of High-Alert Medications.

Appendix 1G In: Leading a Strategic Planning Effort: Pathways for Medication Safety. Chicago, IL: American Hospital Association; 2002.

NEWSPAPER/MAGAZINE ARTICLE

Clear liquids may place patients at risk.

PA-PSRS Patient Saf Advis. December 2005;2:29-31.

COMMENTARY

ISMP medication error report analysis.

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

PRESS RELEASE/ANNOUNCEMENT

Tamiflu (oseltamivir) for oral suspension: potential medication errors.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 25, 2009.

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.

STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

PRESS RELEASE/ANNOUNCEMENT

McNeil Consumer & Specialty Pharmaceuticals announces nationwide recall of Children's Tylenol Meltaways - 80 Mg, Children's Tylenol Softchews - 80 Mg and Jr. Tylenol Meltaways - 160 Mg [press release].

Fort Washington, PA: McNeil Consumer & Specialty Pharmaceuticals; June 3, 2005.

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