AHRQ Patient Safety Network

The Collection > Health Care Executives and Administrators

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Safety Target

•Device-related Complications (106)

•Diagnostic Errors (105)

•Identification Errors (64)

•Discontinuities, Gaps, and Hand-Off Problems (321)

•Fatigue and Sleep Deprivation (107)

•Medication Safety (906)

•Medical Complications (269)

•Nonsurgical Procedural Complications (44)

•Surgical Complications (269)

•Transfusion Complications (13)

•Psychological and Social Complications (109)

Origin/Sponsor

•Asia (20)

•Australia and New Zealand (44)

•Central and South America (2)

•Europe (154)

•North America (2658)

Resource Types

•Clinical Guideline (2)

•Journal Article (2072)

•Legislation/Regulation (41)

•Meeting/Conference (21)

•Newsletter/Journal (9)

•Newspaper/Magazine Article (331)

•Press Release/Announcement (16)

•Special or Theme Issue (60)

•Tools/Toolkit (39)

•Web Resource (65)

•Grant (6)

Error Types

•Epidemiology of Errors and Adverse Events (575)

•Active Errors (269)

•Latent Errors (166)

•Near Miss (53)

Approach to Improving Safety

•Quality Improvement Strategies (800)

•Legal and Policy Approaches (351)

•Error Reporting and Analysis (993)

•Communication Improvement (656)

•Human Factors Engineering (294)

•Teamwork (233)

•Specialization of Care (209)

•Logistical Approaches (250)

•Culture of Safety (515)

•Technologic Approaches (489)

•Education and Training (496)

Clinical Areas

•Allied Health Services (7)

•Medicine (1696)

•Nursing (427)

•Pharmacy (336)

Target Audience
< All

Health Care Executives and Administrators

•Facility and Group Administrators (249)

•Nurse Managers (438)

•Risk Managers (338)

•Quality and Safety Professionals (798)

Setting of Care

•Hospitals (1740)

•Psychiatric Facilities (12)

•Residential Facilities (52)

•Ambulatory Care (198)

•Outpatient Surgery (24)

•Patient Transport (12)

1 - 20 of 2908

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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.

NEWSPAPER/MAGAZINE ARTICLE

Accuracy at every step: the challenge of medication reconciliation.

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

COMMENTARY

Medication reconciliation physician order form.

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

STUDY

Medication safety in the ambulatory chemotherapy setting.

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

COMMENTARY

Developing a medication patient safety program, part 2: process and implementation.

Mark SM, Weber RJ. Hosp Pharm. 2007;42:249–254.

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.

COMMENTARY

Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge.

Rodehaver C. Jt Comm J Qual Patient Saf. 2005;31:406-413.

NEWSPAPER/MAGAZINE ARTICLE

The consumer: and now, a warning about labels.

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

STUDY

The Safety Organizing Scale: development and validation of a behavioral measure of safety culture in hospital nursing units.

Vogus TJ, Sutcliffe KM. Med Care. 2007;45:46-54.

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.

COMMENTARY

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

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

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

Reconciling medications at admission: safe practice recommendations and implementation strategies.

Rogers G, Alper E, Brunelle D, et al. Jt Comm J Qual Patient Saf. 2006;32:37-50.

COMMENTARY

How the US drug safety system should be changed.

Strom BL. JAMA. 2006;295:2072-2075.

COMMENTARY

Pharmacy–nursing intervention to improve accuracy and completeness of medication histories.

Tessier EG, Henneman EA, Nathanson B, Plotkin K, Heelon M. Am J Health Syst Pharm. 2010;67:607-611.

SPECIAL OR THEME ISSUE

Improving Health Care Quality.

Wisc Med J. 2006:105;1-86.

NEWSPAPER/MAGAZINE ARTICLE

An extra dose of safety.

Health Manage Techol. April 2007;28:30-32, 34.

COMMENTARY

Using pharmacogenetics to improve drug safety and efficacy.

Haga SB, Burke W. JAMA. 2004;291:2869-2871.

BOOK/REPORT

Medication Reconciliation Handbook.

Oakbrook Terrace, IL: Joint Commission Resources and the American Society of Health-System Pharmacists; 2006. ISBN: 0866889566.

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