AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (44)

•Diagnostic Errors (46)

•Identification Errors (30)

•Discontinuities, Gaps, and Hand-Off Problems (70)

•Fatigue and Sleep Deprivation (32)

•Medication Safety (238)

•Medical Complications (52)

•Nonsurgical Procedural Complications (28)

•Surgical Complications (111)

•Transfusion Complications (5)

•Psychological and Social Complications (20)

Origin/Sponsor

•Asia (15)

•Australia and New Zealand (23)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (580)

•Legislation/Regulation (7)

•Meeting/Conference (2)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (53)

•Press Release/Announcement (18)

•Special or Theme Issue (6)

•Tools/Toolkit (6)

•Web Resource (6)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (240)

•Active Errors (136)

•Latent Errors (43)

•Near Miss (23)

Approach to Improving Safety

•Quality Improvement Strategies (172)

•Legal and Policy Approaches (72)

•Error Reporting and Analysis (308)

•Communication Improvement (128)

•Human Factors Engineering (107)

•Teamwork (38)

•Specialization of Care (31)

•Logistical Approaches (53)

•Culture of Safety (56)

•Technologic Approaches (109)

•Education and Training (77)

Clinical Areas

•Allied Health Services (3)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (394)

•Psychiatric Facilities (4)

•Residential Facilities (12)

•Ambulatory Care (44)

•Outpatient Surgery (10)

•Patient Transport (10)

1 - 20 of 718

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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

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

Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety.

Collins CM, Elsaid KA. Int J Qual Health Care. 2011;23:36-43.

STUDY

Adverse events and near miss reporting in the NHS.

Shaw R, Drever F, Hughes H, Osborn S, Williams S. Qual Saf Health Care. 2005;14:279-283.

COMMENTARY

In Conversation with...Allan Frankel, MD

AHRQ WebM&M [serial online]. July 2006.

STUDY

The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names.

Darker IT, Gerret D, Filik R, Purdy KJ, Gale AG. Ergonomics. 2011;54:21-33.

STUDY

Impact of implementing alerts about medication black-box warnings in electronic health records.

Yu DT, Seger DL, Lasser KE, et al. Pharmacoepidemiol Drug Saf. 2011;20:192-202.

COMMENTARY

Lessons from "unexpected increased mortality after implementation of a commercially sold computerized physician order entry system."

Sittig DF, Ash JS, Zhang J, Osheroff JA, Shabot MM. Pediatrics. 2006;118:797-801.

STUDY

Improving ambulatory prescribing safety with a handheld decision support system: a randomized controlled trial.

Berner ES, Houston TK, Ray MN, et al. J Am Med Inform Assoc. 2006;13:171-179.

STUDY

Impact of computerized physician order entry on medication prescription errors in the intensive care unit: a controlled cross-sectional trial.

Colpaert K, Claus B, Somers A, Vandewoude K, Robays H, Decruyenaere J. Crit Care. 2006;10:R21.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Safety still compromised by computer weaknesses.

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

STUDY

Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010.

Thomas AN, Taylor RJ. Anaesthesia. 2012;67:706-713.

STUDY

Listen carefully: the risk of error in spoken medication orders.

Lambert BL, Dickey LW, Fisher WM, et al. Soc Sci Med. 2010;70:1599-1608.

STUDY

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.

REVIEW

Clinical errors and medical negligence.

Oyebode F. Med Princ Pract. 2013 Jan 18; [Epub ahead of print].

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

Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.

Lin MY, Hota B, Khan YM, et al; CDC Prevention Epicenter Program. JAMA. 2010;304:2035-2041.

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