AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (26)

•Diagnostic Errors (31)

•Identification Errors (19)

•Discontinuities, Gaps, and Hand-Off Problems (56)

•Fatigue and Sleep Deprivation (25)

•Medication Safety (177)

•Medical Complications (40)

•Nonsurgical Procedural Complications (17)

•Surgical Complications (79)

•Transfusion Complications (4)

•Psychological and Social Complications (18)

Origin/Sponsor

•Asia (13)

•Australia and New Zealand (13)

Resource Types

•Clinical Guideline (1)

•Journal Article (407)

•Legislation/Regulation (7)

•Meeting/Conference (2)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (31)

•Press Release/Announcement (14)

•Special or Theme Issue (5)

•Tools/Toolkit (4)

•Web Resource (5)

Error Types

•Epidemiology of Errors and Adverse Events (159)

•Active Errors (105)

•Latent Errors (31)

•Near Miss (14)

Approach to Improving Safety

•Quality Improvement Strategies (109)

•Legal and Policy Approaches (62)

•Error Reporting and Analysis (205)

•Communication Improvement (110)

•Human Factors Engineering (70)

•Teamwork (28)

•Specialization of Care (22)

•Logistical Approaches (48)

•Culture of Safety (42)

•Technologic Approaches (92)

•Education and Training (61)

Clinical Areas

•Allied Health Services (2)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (287)

•Psychiatric Facilities (3)

•Residential Facilities (11)

•Ambulatory Care (28)

•Outpatient Surgery (6)

•Patient Transport (7)

1 - 20 of 503

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REVIEW

Computerized physician order entry with clinical decision support in long-term care facilities: costs and benefits to stakeholders.

Subramanian S, Hoover S, Gilman B, Field TS, Mutter R, Gurwitz JH. J Am Geriatr Soc. 2007;55:1451-1457.

STUDY

Prescribers' responses to alerts during medication ordering in the long term care setting.

Judge J, Field TS, DeFlorio M, et al. J Am Med Inform Assoc. 2006;13:385-390.

STUDY

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.

STUDY

Computerized physician order entry of injectable antineoplastic drugs: an epidemiologic study of prescribing medication errors.

Nerich V, Limat S, Demarchi M, et al. Int J Med Inform. 2010;79:699-706.

STUDY

Guided prescription of psychotropic medications for geriatric inpatients.

Peterson JF, Kuperman GJ, Shek C, Patel M, Avorn J, Bates DW. Arch Intern Med. 2005;165:802-807.

STUDY

Relationship between quality of care and negligence litigation in nursing homes.

Studdert DM, Spittal MJ, Mello MM, O’Malley AJ, Stevenson DG. N Engl J Med. 2011;364:1243-1250.

STUDY

Clinical application of a computerized system for physician order entry with clinical decision support to prevent adverse drug events in long-term care.

Rochon PA, Field TS, Bates DW, et al. CMAJ. 2006;174:52-54.

STUDY

Patient education to prevent falls among older hospital inpatients: a randomized controlled trial.

Haines TP, Hill A-M, Hill KD, et al. Arch Intern Med. 2011;171:516-524.

STUDY

Patient-specific electronic decision support reduces prescription of excessive doses.

Seidling HM, Schmitt SPW, Bruckner T, et al. Qual Saf Health Care. 2010;19:e15.

STUDY

Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach.

Field TS, Tjia J, Mazor KM, et al. Am J Med. 2011;124:179.e1-179.e7.

STUDY

Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error?

Coleman JJ, Hemming K, Nightingale PG, et al. J R Soc Med. 2011;104:208-218.

STUDY

Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit.

Shulman R, Singer M, Goldstone J, Bellingan G. Crit Care. 2005;9:R516-R521.

COMMENTARY

A living will misinterpreted as a DNR order: confusion compromises patient care.

Katsetos AD, Mirarchi FL. J Emerg Med. 2011;40:629-632.

COMMENTARY

Miscalculated Risk

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

BOOK/REPORT

Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety.

Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.

STUDY

E-prescribing, efficiency, quality: lessons from the computerization of UK family practice.

Schade CP, Sullivan FM, de Lusignan S, Madeley J. J Am Med Inform Assoc. 2006;13:470-475.

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.

REVIEW

Inappropriateness of medication prescriptions to elderly patients in the primary care setting: a systematic review.

Opondo D, Eslami S, Visscher S, et al. PLoS One. 2012;7:e43617.

STUDY

Decreasing errors in pediatric continuous intravenous infusions.

Lehmann CU, Kim GR, Gujral R, Veltri MA, Clark JS, Miller MR. Pediatr Crit Care Med. 2006;7:225-230.

STUDY

Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.

Han YY, Carcillo JA, Venkataraman ST, et al. Pediatrics. 2005;116:1506-1512.

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