AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (9)

•Diagnostic Errors (1)

•Identification Errors (1)

•Discontinuities, Gaps, and Hand-Off Problems (38)

•Medication Safety (417)

•Medical Complications (3)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (2)

•Psychological and Social Complications (1)

Origin/Sponsor

•Australia and New Zealand (7)

•Central and South America (2)

•North America (362)

Resource Types

•Audiovisual (4)

•Book/Report (11)

•Journal Article (301)

•Legislation/Regulation (7)

•Meeting/Conference (2)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (77)

•Press Release/Announcement (3)

•Special or Theme Issue (3)

•Tools/Toolkit (16)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (122)

•Active Errors (51)

•Latent Errors (27)

•Near Miss (6)

Approach to Improving Safety

•Quality Improvement Strategies (97)

•Legal and Policy Approaches (24)

•Error Reporting and Analysis (98)

•Communication Improvement (105)

•Human Factors Engineering (58)

•Teamwork (3)

•Specialization of Care (74)

•Logistical Approaches (22)

•Culture of Safety (23)

•Technologic Approaches (143)

•Education and Training (55)

Clinical Areas

•Allied Health Services (1)

•Medicine (166)

•Nursing (13)

•Pharmacy (348)

Target Audience
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Pharmacists

Setting of Care

•Hospitals (198)

•Psychiatric Facilities (1)

•Residential Facilities (2)

•Ambulatory Care (111)

•Outpatient Surgery (1)

1 - 20 of 430

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STUDY

A steep increase in domestic fatal medication errors with use of alcohol and/or street drugs.

Phillips DP, Barker GEC, Eguchi MM. Arch Intern Med. 2008;168:1561-1566.

AUDIOVISUAL PRESENTATION

Medication error death rate up 500 percent.

Spiesel S, Chadwick A. "Day to Day." National Public Radio. August 27, 2008.

STUDY

Sources and types of discrepancies between electronic medical records and actual outpatient medication use.

Orrico KB. J Manag Care Pharm. 2008;14:626-631.

STUDY

Pharmacist-supported medication review training for general practitioners: feasibility and acceptability.

Krska J, Gill D, Hansford D. Med Educ. 2006;40:1217-1225.

STUDY

Multidisciplinary approach to inpatient medication reconciliation in an academic setting.

Varkey P, Cunningham J, O'Meara J, Bonacci R, Desai N, Sheeler R. Am J Health Syst Pharm. 2007;64:850-854.

STUDY

Medication reconciliation for reducing drug-discrepancy adverse events.

Boockvar KS, Carlson Lacorte H, Giambanco V, Fridman B, Siu A. Am J Geriatr Pharmacother. 2006;4:236-243.

STUDY

classic

A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis.

Avery AJ, Rodgers S, Cantrill JA, et al. Lancet. 2012;379:1310-1319.

STUDY

classic

Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial.

Kripalani S, Roumie CL, Dalal AK, et al; PILL-CVD (Pharmacist Intervention for Low Literacy in Cardiovascular Disease) Study Group. Ann Intern Med. 2012;157:1-10.

STUDY

Ambulatory prescribing errors among community-based providers in two states.

Abramson EL, Bates DW, Jenter C, et al. J Am Med Inform Assoc. 2012;19:644-648.

STUDY

Usability of a computerised drug monitoring programme to detect adverse drug events and non-compliance in outpatient ambulatory care.

Auger C, Forster AJ, Oake N, Tamblyn R. BMJ Qual Saf. 2013;22:306-316.

STUDY

Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.

Walker PC, Bernstein SJ, Tucker Jones JN, et al. Arch Intern Med. 2009;169:2003-2010.

STUDY

Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients.

Gizzi LA, Slain D, Hare JT, Sager R, Briggs F 3rd, Palmer CH. Am J Geriatr Pharmacother. 2010;8:127-135.

STUDY

Using nurses and office staff to report prescribing errors in primary care.

Kennedy AG, Littenberg B, Senders JW. Int J Qual Health Care. 2008;20:238-245.

STUDY

Challenges in posthospital care: nurses as coaches for medication management.

Costa LL, Poe SS, Lee MC. J Nurs Care Qual. 2011;26:243-251.

COMMENTARY

Mandatory pharmacy residencies: one way to reduce medication errors.

Ibrahim RB, Bahgat-Ibrahim L, Reeves D. Am J Health Syst Pharm. 2010;67:477-481.

STUDY

Bayesian cohort and cross-sectional analyses of the PINCER trial: a pharmacist-led intervention to reduce medication errors in primary care.

Hemming K, Chilton PJ, Lilford RJ, Avery A, Sheikh A. PLoS ONE. 2012;7:e38306.

STUDY

Health literacy and medication understanding among hospitalized adults.

Marvanova M, Roumie CL, Eden SK, Cawthon C, Schnipper JL, Kripalani S. J Hosp Med. 2011;6:488-493.

STUDY

Medication error identification rates by pharmacy, medical, and nursing students.

Warholak TL, Queiruga C, Roush R, Phan H. Am J Pharm Educ. 2011;75:24.

STUDY

Retail pharmacy staff perceptions of design strengths and weaknesses of electronic prescribing.

Odukoya O, Chui MA. J Am Med Inform Assoc. 2012;19:1059-1065.

STUDY

Diagramming patients' views of root causes of adverse drug events in ambulatory care: an online tool for planning education and research.

Brown M, Frost R, Ko Y, Woosley R. Patient Educ Couns. 2006;62:302-315.

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