AHRQ Patient Safety Network

The Collection > Physicians

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Safety Target

•Device-related Complications (42)

•Diagnostic Errors (115)

•Identification Errors (30)

•Discontinuities, Gaps, and Hand-Off Problems (142)

•Fatigue and Sleep Deprivation (62)

•Medication Safety (331)

•Medical Complications (47)

•Nonsurgical Procedural Complications (24)

•Surgical Complications (199)

•Transfusion Complications (3)

•Psychological and Social Complications (52)

Origin/Sponsor

•Asia (12)

•Australia and New Zealand (22)

•Central and South America (1)

•Europe (90)

•North America (1005)

Resource Types

•Audiovisual (11)

•Book/Report (27)

•Clinical Guideline (7)

•Journal Article (914)

•Legislation/Regulation (18)

•Meeting/Conference (4)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (130)

•Press Release/Announcement (12)

•Special or Theme Issue (10)

•Tools/Toolkit (16)

•Web Resource (19)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (219)

•Active Errors (165)

•Latent Errors (66)

•Near Miss (17)

Approach to Improving Safety

•Quality Improvement Strategies (296)

•Legal and Policy Approaches (98)

•Error Reporting and Analysis (321)

•Communication Improvement (283)

•Human Factors Engineering (101)

•Teamwork (85)

•Specialization of Care (51)

•Logistical Approaches (103)

•Culture of Safety (91)

•Technologic Approaches (192)

•Education and Training (248)

Clinical Areas

•Allied Health Services (3)

Target Audience
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Physicians

Setting of Care

•Hospitals (602)

•Psychiatric Facilities (2)

•Residential Facilities (6)

•Ambulatory Care (100)

•Outpatient Surgery (14)

•Patient Transport (3)

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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.

FACT SHEET/FAQS

Oral Dosage Forms that Should Not Be Crushed.

Mitchell JF. Institute for Safe Medication Practices.

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.

COMMENTARY

New technology, new errors: how to prime an upgrade of an insulin infusion pump.

Rule AM, Drincic A, Galt KA. Jt Comm J Qual Patient Saf. 2007;33:155-162.

COMMENTARY

SNOMED CT: electronic health record enhances anesthesia patient safety.

Elevitch FR. AANA J. 2005;73:361-366.

NEWSPAPER/MAGAZINE ARTICLE

Clear liquids may place patients at risk.

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

COMMENTARY

Preventing vincristine administration errors: does evidence support minibag infusions?

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

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

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

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

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.

ORGANIZATIONAL POLICY/GUIDELINES

Tubing misconnections—a persistent and potentially deadly occurrence.

Sentinel Event Alert. April 3, 2006;(36):1-3.

NEWSPAPER/MAGAZINE ARTICLE

Double key bounce and double keying errors.

ISMP Medication Safety Alert! Acute Care Edition. January 12, 2006;11:1-2.

ORGANIZATIONAL POLICY/GUIDELINES

2008 Recommendations for Pre-Anesthesia Checkout Procedures.

ASA Committee on Equipment and Facilities. Park Ridge, IL: American Society of Anesthesiologists; 2008.

NEWSPAPER/MAGAZINE ARTICLE

Medication administration in anesthesia: time for a paradigm shift.

Stabile M, Webster CS, Merry AF. APSF Newsletter. Fall 2007;22:44-47.

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.

STUDY

Evaluation of a Web-based education program on reducing medication dosing error: a multicenter, randomized controlled trial.

Frush K, Hohenhaus S, Luo X, Gerardi M, Wiebe RA. Pediatr Emerg Care. 2006;22:62-70.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing vincristine administration errors.

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

COMMENTARY

Patient safety in plastic surgery.

Trussler AP, Tabbal GN. Plast Reconstr Surg. 2012;130:470e-478e.

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