AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (48)

•Diagnostic Errors (65)

•Identification Errors (32)

•Discontinuities, Gaps, and Hand-Off Problems (81)

•Fatigue and Sleep Deprivation (43)

•Medication Safety (259)

•Medical Complications (60)

•Nonsurgical Procedural Complications (31)

•Surgical Complications (114)

•Transfusion Complications (5)

•Psychological and Social Complications (27)

Origin/Sponsor

•Asia (25)

•Australia and New Zealand (23)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (672)

•Legislation/Regulation (9)

•Meeting/Conference (2)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (68)

•Press Release/Announcement (16)

•Special or Theme Issue (7)

•Tools/Toolkit (6)

•Web Resource (6)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (279)

•Active Errors (152)

•Latent Errors (48)

•Near Miss (25)

Approach to Improving Safety

•Quality Improvement Strategies (180)

•Legal and Policy Approaches (98)

•Error Reporting and Analysis (370)

•Communication Improvement (151)

•Human Factors Engineering (123)

•Teamwork (38)

•Specialization of Care (33)

•Logistical Approaches (69)

•Culture of Safety (66)

•Technologic Approaches (118)

•Education and Training (92)

Clinical Areas

•Allied Health Services (2)

•Medicine (553)

•Nursing (39)

•Pharmacy (85)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (457)

•Psychiatric Facilities (2)

•Residential Facilities (11)

•Ambulatory Care (50)

•Outpatient Surgery (11)

•Patient Transport (8)

1 - 20 of 830

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COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:282-287.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

REVIEW

Bar code technology and medication administration error.

Young J, Slebodnik M, Sands L. J Patient Saf. 2010;6;115-120.

STUDY

Origins of and solutions for neonatal medication-dispensing errors.

Sauberan JB, Dean LM, Fiedelak J, Abraham JA. Am J Health Syst Pharm. 2010;67:49-57.

NEWSPAPER/MAGAZINE ARTICLE

Collaboration focused on priority issues promotes safety.

ISMP Medication Safety Alert! Acute Care Edition. October 10, 2008;13:1-3.

STUDY

Prevention of pediatric medication errors by hospital pharmacists and the potential benefit of computerized physician order entry.

Wang JK, Herzog NS, Kaushal R, et al. Pediatrics. 2007;119:e77-85.

STUDY

Effects of mental demands during dispensing on perceived medication safety and employee well-being: a study of workload in pediatric hospital pharmacies.

Holden RJ, Patel NR, Scanlon MC, Shalaby TM, Arnold JM, Karsh BT. Res Social Admin Pharm. 2010;6:293-306.

NEWSPAPER/MAGAZINE ARTICLE

Fatal outcome after inadvertent injection of topical epinephrine.

ISMP Medication Safety Alert! Acute Care Edition. March 26, 2009;14:1-2.

STUDY

Enhancing medication use safety: benefits of learning from your peers.

Kazandjian VA, Ogunbo S, Wicker KG, Vaida AJ, Pipesh F. Qual Saf Health Care. 2009;18:331-335.

COMMENTARY

ISMP medication error report analysis.

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

STUDY

Medication errors recovered by emergency department pharmacists.

Rothschild JM, Churchill W, Erickson A, et al. Ann Emerg Med. 2010;55:513-521.

STUDY

Potassium and phosphorus repletion in hospitalized patients: implications for clinical practice and the potential use of healthcare information technology to improve prescribing and patient safety.

Hemstreet BA, Stolpman N, Badesch DB, May SK, McCollum M. Curr Med Res Opin. 2006;22:2449-2455.

NEWSPAPER/MAGAZINE ARTICLE

Safety still compromised by computer weaknesses.

ISMP Medication Safety Alert! Acute Care Edition. August 25, 2005;10:1-3.

COMMENTARY

Miscalculated Risk

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

NEWSPAPER/MAGAZINE ARTICLE

Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition.

ISMP Medication Safety Alert! Acute Care Edition. September 22, 2011;16:1-3.

STUDY

Potential medication dosing errors in outpatient pediatrics.

McPhillips HA, Stille CJ, Smith D, et al. J Pediatr. 2005;147:761-767.

NEWSPAPER/MAGAZINE ARTICLE

Preventing catheter/tubing misconnections: much needed help is on the way.

ISMP Medication Safety Alert! Acute Care Edition. July 15, 2010;15:1-2.

NEWSPAPER/MAGAZINE ARTICLE

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.

STUDY

Antiretroviral medication errors among hospitalized patients with HIV infection.

Rastegar DA, Knight AM, Monolakis JS. Clin Infect Dis. 2006;43:933-38.

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