AHRQ Patient Safety Network

The Collection > Nurses

PATIENT SAFETY PRIMERS
Nursing and Patient Safety

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Safety Target

•Device-related Complications (47)

•Diagnostic Errors (8)

•Identification Errors (29)

•Discontinuities, Gaps, and Hand-Off Problems (100)

•Fatigue and Sleep Deprivation (20)

•Medication Safety (348)

•Medical Complications (80)

•Nonsurgical Procedural Complications (17)

•Surgical Complications (103)

•Transfusion Complications (2)

•Psychological and Social Complications (20)

Origin/Sponsor

•Asia (21)

•Australia and New Zealand (34)

•Central and South America (3)

Resource Types

•Clinical Guideline (5)

•Journal Article (725)

•Legislation/Regulation (13)

•Meeting/Conference (3)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (68)

•Press Release/Announcement (8)

•Special or Theme Issue (14)

•Tools/Toolkit (15)

•Web Resource (11)

Error Types

•Epidemiology of Errors and Adverse Events (142)

•Active Errors (121)

•Latent Errors (51)

•Near Miss (21)

Approach to Improving Safety

•Quality Improvement Strategies (229)

•Legal and Policy Approaches (31)

•Error Reporting and Analysis (193)

•Communication Improvement (211)

•Human Factors Engineering (120)

•Teamwork (97)

•Specialization of Care (45)

•Logistical Approaches (103)

•Culture of Safety (121)

•Technologic Approaches (127)

•Education and Training (169)

Clinical Areas

•Allied Health Services (3)

•Medicine (484)

•Nursing (479)

•Pharmacy (76)

Target Audience
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Nurses

Setting of Care

•Hospitals (561)

•Psychiatric Facilities (5)

•Residential Facilities (16)

•Ambulatory Care (39)

•Outpatient Surgery (3)

•Patient Transport (4)

1 - 20 of 886

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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.

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.

STUDY

Adverse drug events caused by serious medication administration errors.

Kale A, Keohane CA, Maviglia S, Gandhi TK, Poon EG. BMJ Qual Saf. 2012;21:933-938.

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.

NEWSPAPER/MAGAZINE ARTICLE

Medical simulations identify potential problems before they can pose a real threat.

Kleefeld E. Wisconsin Technology Network. June 15, 2005.

STUDY

Effects of technological interventions on the safety of a medication-use system.

Skibinski KA, White BA, Lin LI, Dong Y, Wu W. Am J Health Syst Pharm. 2007;64:90-96.

MULTI-USE WEBSITE

Surgical Care Improvement Project.

National SCIP Partnership, Oklahoma Foundation for Medical Quality, 14000 Quail Springs Parkway, Suite 400, Oklahoma City, OK, 73134.

AUDIOVISUAL

Preventing fatal heparin overdoses.

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

ORGANIZATIONAL POLICY/GUIDELINES

Statement on the prevention of retained foreign bodies after surgery.

Bulletin of the American College of Surgeons; October 2005.

STUDY

Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.

Colligan L, Guerlain S, Steck SE, Hoke TR. BMJ Qual Saf. 2012;21:939-947.

COMMENTARY

ISMP medication error report analysis.

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

FACT SHEET/FAQS

Medication safety issue brief. Counterfeit drug prevention and identification.

American Hospital Association, American Society of Health-System Pharmacists, Hospitals and Health Networks. Hosp Health Netw. August 2005;79.29-30.

COMMENTARY

Time to get off this pig's back?: the human factors aspects of the mismatch between device and real-world knowledge in the health care environment.

Nunnally ME, Bitan Y. J Patient Saf. 2006;2:124-131.

STUDY

A system factors analysis of "line, tube, and drain" incidents in the intensive care unit.

Needham DM, Sinopoli DJ, Thompson DA, et al. Crit Care Med. 2005;33:1701-1707.

FACT SHEET/FAQS

Medication safety issue brief. Bar code implementation strategies.

American Hospital Association, American Society of Health-System Pharmacists, Hospitals and Health Networks. Hosp Health Netw. July 2005;79:65-66.

NEWSPAPER/MAGAZINE ARTICLE

Scanning out medication errors: Ohio Valley Hospital's automated IV system provides real-time access to patient data.

Carbasho T. Pittsburgh Business Times. April 25, 2005.

NEWSPAPER/MAGAZINE ARTICLE

What pilots can teach hospitals about patient safety.

Murphy K. New York Times. October 31, 2006:F5.

COMMENTARY

Miscalculated Risk

Strassels SA. AHRQ WebM&M [serial online]. August 2006.

COMMENTARY

Creating high reliability in health care organizations.

Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Health Serv Res. 2006;41:1599-1617.

STUDY

Increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port.

Maragakis LL, Bradley KL, Song X, et al. Infect Control Hosp Epidemiol. 2006;27:67-70.

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