AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (9)

•Diagnostic Errors (22)

•Identification Errors (14)

•Discontinuities, Gaps, and Hand-Off Problems (68)

•Fatigue and Sleep Deprivation (26)

•Medication Safety (146)

•Medical Complications (34)

•Nonsurgical Procedural Complications (2)

•Surgical Complications (38)

•Transfusion Complications (2)

•Psychological and Social Complications (15)

Origin/Sponsor

•Australia and New Zealand (24)

•North America (346)

Resource Types

•Audiovisual (1)

•Book/Report (23)

•Clinical Guideline (1)

•Journal Article (366)

•Legislation/Regulation (5)

•Meeting/Conference (2)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (38)

•Press Release/Announcement (1)

•Special or Theme Issue (3)

•Tools/Toolkit (13)

•Web Resource (10)

Error Types

•Epidemiology of Errors and Adverse Events (101)

•Active Errors (46)

•Latent Errors (27)

•Near Miss (12)

Approach to Improving Safety

•Quality Improvement Strategies (144)

•Legal and Policy Approaches (45)

•Error Reporting and Analysis (158)

•Communication Improvement (107)

•Human Factors Engineering (35)

•Teamwork (36)

•Specialization of Care (31)

•Logistical Approaches (51)

•Culture of Safety (81)

•Technologic Approaches (106)

•Education and Training (73)

Clinical Areas

•Allied Health Services (2)

•Complementary and Alternative Medicine (1)

•Medicine (277)

•Nursing (20)

•Pharmacy (20)

Target Audience
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Facility and Group Administrators

Setting of Care

•Hospitals (238)

•Psychiatric Facilities (1)

•Residential Facilities (19)

•Ambulatory Care (79)

•Outpatient Surgery (8)

•Patient Transport (4)

1 - 20 of 465

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COMMENTARY

The challenge of medication reconciliation.

Patient Safety & Quality Healthcare. May 10, 2006.

STUDY

Implementation of a medication reconciliation process in an ambulatory internal medicine clinic.

Nassaralla CL, Naessens JM, Chaudhry R, Hansen MA, Scheitel SM. Qual Saf Health Care. 2007;16:90-94.

STUDY

Alternatives to potentially inappropriate medications for use in e-prescribing software: triggers and treatment algorithms.

Hume AL, Quilliam BJ, Goldman R, Eaton C, Lapane KL. BMJ Qual Saf. 2011;20:875-884.

STUDY

Patient report on information given, consultation time and safety in primary care.

Mira JJ, Nebot C, Lorenzo S, Pérez-Jover V. Qual Saf Health Care. 2010;19:e33.

STUDY

Delayed or missed diagnosis of cervical spine injuries.

Platzer P, Hauswirth N, Jaindl M, Chatwani S, Vecsei V, Gaebler C. J Trauma. 2006;61:150-155.

COMMENTARY

It's All in the Syringe

Weingart SN. AHRQ WebM&M [serial online]. August 2006.

STUDY

Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge.

Schnipper JL, Liang CL, Hamann C, et al. J Am Med Inform Assoc. 2011;18:309-313.

REVIEW

Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice.

Stille CJ, Jerant A, Bell D, Meltzer D, Elmore JG. Ann Intern Med. 2005;142:700-708.

STUDY

Using a preprinted order sheet to reduce prescription errors in a pediatric emergency department: a randomized, controlled trial.

Kozer E, Scolnik D, MacPherson A, Rauchwerger D, Koren G. Pediatrics. 2005;116:1299-1302.

STUDY

Using an electronic prescribing system to ensure accurate medication lists in a large multidisciplinary medical group.

Stock R, Scott J, Gurtel S. Jt Comm J Qual Patient Saf. 2009;35:271-279.

STUDY

The management of test results in primary care: does an electronic medical record make a difference?

Elder NC, McEwen TR, Flach J, Gallimore J, Pallerla H. Fam Med. 2010;42:327-333.

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.

STUDY

Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin.

Donihi AC, DiNardo MM, DeVita MA, Korytkowski MT. Qual Saf Health Care. 2006;15:89-91.

STUDY

Electronic results management in pediatric ambulatory care: qualitative assessment.

Ferris TG, Johnson SA, Co JP, et al. Pediatrics. 2009;123(suppl 2):S85-S91.

STUDY

Risk of medication errors at hospital discharge and barriers to problem resolution.

Enguidanos SM, Brumley RD. Home Health Care Serv Q. 2005;24:123-135.

STUDY

Approaches to reducing the most important patient errors in primary health-care: patient and professional perspectives.

Buetow S, Kiata L, Liew T, Kenealy T, Dovey S, Elwyn G. Health Soc Care Community. 2010;18:296-303.

COMMENTARY

Unintended errors with EHR-based result management: a case series.

Yackel TR, Embi PJ. J Am Med Inform Assoc. 2010;17:104-107.

TOOLKIT

Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation.

Gleason KM, Brake H, Agramonte V, Perfetti C. Rockville, MD: Agency for Healthcare Research and Quality; Revised August 2012. AHRQ Publication No. 11(12)-0059.

STUDY

Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL study.

Zwart DL, Steerneman AH, van Rensen EL, Kalkman CJ, Verheij TJ. BMJ Qual Saf. 2011;20:121-127.

REVIEW

Safety learning system development—incident reporting component for family practice.

O'Beirne M, Sterling P, Reid R, Tink W, Hohman S, Norton P. Qual Saf Health Care. 2010;19:252-257.

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