AHRQ Patient Safety Network

The Collection > Nurses

PATIENT SAFETY PRIMERS
Nursing and Patient Safety

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Safety Target

•Device-related Complications (45)

•Diagnostic Errors (8)

•Identification Errors (29)

•Discontinuities, Gaps, and Hand-Off Problems (94)

•Fatigue and Sleep Deprivation (16)

•Medication Safety (333)

•Medical Complications (69)

•Nonsurgical Procedural Complications (15)

•Surgical Complications (104)

•Transfusion Complications (2)

•Psychological and Social Complications (19)

Origin/Sponsor

•Asia (14)

•Australia and New Zealand (23)

•Central and South America (3)

Resource Types

•Clinical Guideline (5)

•Journal Article (682)

•Legislation/Regulation (14)

•Meeting/Conference (3)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (65)

•Press Release/Announcement (8)

•Special or Theme Issue (12)

•Tools/Toolkit (15)

•Web Resource (11)

Error Types

•Epidemiology of Errors and Adverse Events (142)

•Active Errors (114)

•Latent Errors (48)

•Near Miss (20)

Approach to Improving Safety

•Quality Improvement Strategies (219)

•Legal and Policy Approaches (29)

•Error Reporting and Analysis (179)

•Communication Improvement (201)

•Human Factors Engineering (111)

•Teamwork (88)

•Specialization of Care (42)

•Logistical Approaches (90)

•Culture of Safety (106)

•Technologic Approaches (127)

•Education and Training (160)

Clinical Areas

•Allied Health Services (2)

•Medicine (465)

•Nursing (432)

•Pharmacy (76)

Target Audience
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Nurses

Setting of Care

•Hospitals (532)

•Psychiatric Facilities (5)

•Residential Facilities (14)

•Ambulatory Care (35)

•Outpatient Surgery (3)

•Patient Transport (3)

1 - 20 of 836

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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.

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.

STUDY

Errors associated with medications removed from automated dispensing machines using override functions.

Kester K, Baxter J, Freudenthal K. Hosp Pharm. 2006;41:535-537.

STUDY

Improving patient safety by identifying side effects from introducing bar coding in medication administration.

Patterson ES, Cook RI, Render ML. J Am Med Inform Assoc. 2002;9:540-553.

STUDY

Effectiveness of a computerized system for intravenous heparin administration: using information technology to improve patient care and patient safety.

Oyen LJ, Nishimura RA, Ou NN, Armon JJ, Zhou M. Am Heart Hosp J. 2005;3:75-81.

COMMENTARY

ISMP medication error report analysis.

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

STUDY

High rates of adverse drug events in a highly computerized hospital.

Nebeker JR, Hoffman JM, Weir CR, Bennett CL, Hurdle JF. Arch Intern Med. 2005;165:1111-1116.

NEWSPAPER/MAGAZINE ARTICLE

Clear liquids may place patients at risk.

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

TOOLKIT

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

Huntington Valley, PA: Institute for Safe Medication Practices.

STUDY

Relationship of incorrect dosing of fibrinolytic therapy and clinical outcomes.

Mehta RH, Alexander JH, Van de Werf F, et al. JAMA. 2005;293:1746-1750.

COMMENTARY

Medication bar coding: to scan or not to scan?

Galvin L, McBeth S, Hasdorff C, Tillson M, Thomas S. Comput Inform Nurs. 2007;25:86-92.

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

The effects of computerized provider order entry implementation on communication in intensive care units.

Hoonakker PL, Carayon P, Walker JM, Brown RL, Cartmill RS. Int J Med Inform. 2013;82:e107-e117.

COMMENTARY

Surprise Wire

Pearl JM, Donaldson NE. AHRQ WebM&M [serial online]. July/August 2005.

FACT SHEET/FAQS

Oral Dosage Forms that Should Not Be Crushed.

Mitchell JF. Institute for Safe Medication Practices.

COMMENTARY

Improving the safety of medication administration using an interactive CD-ROM program.

Schneider PJ, Pedersen CA, Montanya KR, et al. Am J Health Syst Pharm. 2006;63:59-64.

COMMENTARY

Medication orders are written clearly and transcribed accurately – implementing Medication Management Standard 3.20 and National Patient Safety Goal 2b.

Laselle TJ,May SK. Hosp Pharm. 2006;41:82-87.

COMMENTARY

ISMP medication error report analysis.

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

STUDY

Medication dosing errors for patients with renal insufficiency in ambulatory care.

Yap C, Dunham D, Thompson J, Baker D. Jt Comm J Qual Patient Saf. 2005;31:514-521.

STUDY

Computerized provider order entry implementation: no association with increased mortality rates in an intensive care unit.

Del Beccaro MA, Jeffries HE, Eisenberg MA, Harry ED. Pediatrics. 2006;118:290-295.

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