AHRQ Patient Safety Network

The Collection > Nurses

PATIENT SAFETY PRIMERS
Nursing and Patient Safety

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Safety Target

•Device-related Complications (44)

•Diagnostic Errors (8)

•Identification Errors (28)

•Discontinuities, Gaps, and Hand-Off Problems (93)

•Fatigue and Sleep Deprivation (17)

•Medication Safety (330)

•Medical Complications (69)

•Nonsurgical Procedural Complications (15)

•Surgical Complications (102)

•Transfusion Complications (2)

•Psychological and Social Complications (19)

Origin/Sponsor

•Asia (15)

•Australia and New Zealand (23)

•Central and South America (3)

Resource Types

•Clinical Guideline (5)

•Journal Article (681)

•Legislation/Regulation (13)

•Meeting/Conference (3)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (64)

•Press Release/Announcement (8)

•Special or Theme Issue (12)

•Tools/Toolkit (15)

•Web Resource (11)

Error Types

•Epidemiology of Errors and Adverse Events (139)

•Active Errors (113)

•Latent Errors (48)

•Near Miss (18)

Approach to Improving Safety

•Quality Improvement Strategies (218)

•Legal and Policy Approaches (29)

•Error Reporting and Analysis (185)

•Communication Improvement (198)

•Human Factors Engineering (111)

•Teamwork (88)

•Specialization of Care (42)

•Logistical Approaches (91)

•Culture of Safety (110)

•Technologic Approaches (122)

•Education and Training (159)

Clinical Areas

•Allied Health Services (2)

•Medicine (465)

•Nursing (434)

•Pharmacy (75)

Target Audience
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Nurses

Setting of Care

•Hospitals (529)

•Psychiatric Facilities (5)

•Residential Facilities (15)

•Ambulatory Care (34)

•Outpatient Surgery (3)

•Patient Transport (2)

1 - 20 of 834

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COMMENTARY

Preventing vincristine administration errors: does evidence support minibag infusions?

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

NEWSPAPER/MAGAZINE ARTICLE

Practitioners agree on medication reconciliation value, but frustration and difficulties abound.

ISMP Medication Safety Alert! Acute Care Edition. July 13, 2006;11:1-2.

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

Fatality involving vinblastine overdose as a result of a complex medical error.

Klys M, Konopka T, Scislowski M, Kowalski P. Cancer Chemother Pharmacol. 2007;59:89-95.

NEWSPAPER/MAGAZINE ARTICLE

Building a case for medication reconciliation.

Nurse Advise-ERR. April 2006;4:1-3.

FACT SHEET/FAQS

Oral Dosage Forms that Should Not Be Crushed.

Mitchell JF. Institute for Safe Medication Practices.

STUDY

Medication safety in the ambulatory chemotherapy setting.

Gandhi TK, Bartel SB, Shulman LN, et al. Cancer. 2005;104:2477-2483.

NEWSPAPER/MAGAZINE ARTICLE

Clear liquids may place patients at risk.

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

NEWSPAPER/MAGAZINE ARTICLE

New practices reduce childbirth risks.

Landro L. Wall Street Journal. July 12, 2006:D1. [Reprinted on Post-gazette.com].

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.

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.

COMMENTARY

Medication reconciliation physician order form.

Lacy JL, Wilkinson ST. Hosp Pharm. 2006;41:1117-1120.

STUDY

An overview of intravenous-related medication administration errors as reported to MEDMARX^(R), a national medication error-reporting program.

Hicks RW, Becker SC. J Infus Nurs. 2006;29:20-27.

COMMENTARY

ISMP medication error report analysis.

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

STUDY

Child-specific risk factors and patient safety.

Woods DM, Holl JL, Shonkoff JP, Mehra M, Ogata ES, Weiss KB. J Patient Saf. 2005;1:17-22.

STUDY

Assessing and monitoring override medications in automated dispensing devices.

Kowiatek JG, Weber RJ, Skledar SJ, Frank S, DeVita M. Jt Comm J Qual Patient Saf. 2006;32:309-317.

NEWSPAPER/MAGAZINE ARTICLE

Accuracy at every step: the challenge of medication reconciliation.

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

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

Bar-code technology for medication administration: medication errors and nurse satisfaction.

Fowler SB, Sohler P, Zarillo DF. MedSurg Nursing. 2009;18:103-110.

NEWSPAPER/MAGAZINE ARTICLE

The consumer: and now, a warning about labels.

Franklin D. New York Times. October 25, 2005:F1.

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