AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (46)

•Diagnostic Errors (65)

•Identification Errors (32)

•Discontinuities, Gaps, and Hand-Off Problems (83)

•Fatigue and Sleep Deprivation (43)

•Medication Safety (254)

•Medical Complications (61)

•Nonsurgical Procedural Complications (32)

•Surgical Complications (119)

•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 (681)

•Legislation/Regulation (9)

•Meeting/Conference (2)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (67)

•Press Release/Announcement (17)

•Special or Theme Issue (7)

•Tools/Toolkit (6)

•Web Resource (7)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (279)

•Active Errors (151)

•Latent Errors (49)

•Near Miss (26)

Approach to Improving Safety

•Quality Improvement Strategies (184)

•Legal and Policy Approaches (103)

•Error Reporting and Analysis (373)

•Communication Improvement (156)

•Human Factors Engineering (118)

•Teamwork (41)

•Specialization of Care (33)

•Logistical Approaches (69)

•Culture of Safety (64)

•Technologic Approaches (119)

•Education and Training (95)

Clinical Areas

•Allied Health Services (3)

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Risk Managers

Setting of Care

•Hospitals (456)

•Psychiatric Facilities (2)

•Residential Facilities (12)

•Ambulatory Care (52)

•Outpatient Surgery (11)

•Patient Transport (8)

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COMMENTARY

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.

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

Hospital do-not-resuscitate orders: why they have failed and how to fix them.

Yuen JK, Reid MC, Fetters MD. J Gen Intern Med. 2011;26:791-797.

STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

BOOK/REPORT classic

The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives.

Maxfield D, Grenny J, Lavandero R, Groah L. Provo, UT: VitalSmarts; 2011.

NEWSPAPER/MAGAZINE ARTICLE

Collaboration focused on priority issues promotes safety.

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

STUDY

Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance.

Classen DC, Jaser L, Budnitz DS. Jt Comm J Qual Patient Saf. 2010;36:12-21, AP1-AP9.

COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

STUDY

Disclosure-and-resolution programs that include generous compensation offers may prompt a complex patient response.

Murtagh L, Gallagher TH, Andrew P, Mello MM. Health Aff (Millwood). 2012;31:2681-2689.

STUDY

Determinants of patient-reported medication errors: a comparison among seven countries.

Lu CY, Roughead E. Int J Clin Pract. 2011;65:733-740.

STUDY

Pediatric antidepressant medication errors in a national error reporting database.

Rinke ML, Bundy DG, Shore AD, Colantuoni E, Morlock LL, Miller MR. J Dev Behav Pediatr. 2010;31:129-136.

BOOK/REPORT

Saving Lives, Saving Money: The Imperative for Computerized Physician Order Entry in Massachusetts Hospitals.

Adams M, Bates D, Coffman G, Everett W. Westborough, MA: Massachusetts Technology Collaborative and New England Healthcare Institute; 2008.

REVIEW

Bar code technology and medication administration error.

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

STUDY

The costs of adverse drug events in community hospitals.

Hug BL, Keohane C, Seger DL, Yoon C, Bates DW. Jt Comm J Qual Patient Saf. 2012;38:120-126.

STUDY

Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.

Brady PW, Muething S, Kotagal U, et al. Pediatrics. 2013;131:e298-e308.

STUDY

Disclosure of hospital adverse events and its association with patients' ratings of the quality of care.

López L, Weissman JS, Schneider EC, Weingart SN, Cohen AP, Epstein AM. Arch Intern Med. 2009;169:1888-1894.

NEWSPAPER/MAGAZINE ARTICLE

DTaP–Tdap mix-ups now affecting hundreds of patients.

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

COMMENTARY

Implementation of a specialized pharmacy team to monitor high-risk medications during discharge.

Martin ES III, Overstreet RL, Jackson-Khalil LR, McCollough HL, Meyer TA, Xu Q. Am J Health Syst Pharm. 2013;70:18-21.

STUDY

Recognition of adverse drug events in older hospitalized medical patients.

Klopotowska JE, Wierenga PC, Smorenburg SM, et al; WINGS study group. Eur J Clin Pharmacol. 2013;69:75-85.

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