AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (47)

•Diagnostic Errors (69)

•Identification Errors (35)

•Discontinuities, Gaps, and Hand-Off Problems (84)

•Fatigue and Sleep Deprivation (45)

•Medication Safety (257)

•Medical Complications (62)

•Nonsurgical Procedural Complications (32)

•Surgical Complications (124)

•Transfusion Complications (5)

•Psychological and Social Complications (26)

Origin/Sponsor

•Asia (22)

•Australia and New Zealand (28)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (695)

•Legislation/Regulation (9)

•Meeting/Conference (2)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (68)

•Press Release/Announcement (12)

•Special or Theme Issue (6)

•Tools/Toolkit (6)

•Web Resource (7)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (290)

•Active Errors (154)

•Latent Errors (48)

•Near Miss (24)

Approach to Improving Safety

•Quality Improvement Strategies (191)

•Legal and Policy Approaches (98)

•Error Reporting and Analysis (380)

•Communication Improvement (155)

•Human Factors Engineering (118)

•Teamwork (40)

•Specialization of Care (32)

•Logistical Approaches (72)

•Culture of Safety (64)

•Technologic Approaches (119)

•Education and Training (99)

Clinical Areas

•Allied Health Services (2)

•Medicine (571)

•Nursing (45)

•Pharmacy (83)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (458)

•Psychiatric Facilities (3)

•Residential Facilities (11)

•Ambulatory Care (51)

•Outpatient Surgery (12)

•Patient Transport (9)

1 - 20 of 849

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STUDY

Intralipid medication errors in the neonatal intensive care unit.

Chuo J, Lambert G, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:104-111.

NEWSPAPER/MAGAZINE ARTICLE

Promethazine conundrum: IV can hurt more than IM injection!

ISMP Medication Safety Alert! Acute Care Edition. November 2, 2006;11:1-3.

STUDY

Adverse drug events caused by serious medication administration errors.

Kale A, Keohane CA, Maviglia S, Gandhi TK, Poon EG. BMJ Qual Saf. 2012;21:933-938.

STUDY

Child-specific risk factors and patient safety.

Woods DM, Holl JL, Shonkoff JP, Mehra M, Ogata ES, Weiss KB. J Patient Saf. 2005;1:17-22.

NEWSPAPER/MAGAZINE ARTICLE

Medical simulations identify potential problems before they can pose a real threat.

Kleefeld E. Wisconsin Technology Network. June 15, 2005.

STUDY

Oral outpatient chemotherapy medication errors in children with acute lymphoblastic leukemia.

Taylor JA, Winter L, Geyer LJ, Hawkins DS. Cancer. 2006;107:1400-1406.

STUDY

Effects of technological interventions on the safety of a medication-use system.

Skibinski KA, White BA, Lin LI, Dong Y, Wu W. Am J Health Syst Pharm. 2007;64:90-96.

STUDY

Computer based medication error reporting: insights and implications.

Miller MR, Clark JS, Lehmann CU. Qual Saf Health Care. 2006;15:208-213.

MULTI-USE WEBSITE

Surgical Care Improvement Project.

National SCIP Partnership, Oklahoma Foundation for Medical Quality, 14000 Quail Springs Parkway, Suite 400, Oklahoma City, OK, 73134.

AUDIOVISUAL

Preventing fatal heparin overdoses.

Food and Drug Administration (FDA) Patient Safety News. Show #58. December 2006.

BOOK/REPORT

Annual Benchmarking Report: Malpractice Risks in Surgery.

Cambridge, MA: CRICO/RMF Strategies; 2010.

STUDY

Work-hour restrictions as an ethical dilemma for residents.

Carpenter RO, Austin MT, Tarpley JL, Griffin MR, Lomis KD. Amer J Surg. 2006;191:527-532.

ORGANIZATIONAL POLICY/GUIDELINES

Statement on the prevention of retained foreign bodies after surgery.

Bulletin of the American College of Surgeons; October 2005.

STUDY

The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer.

Raab SS, Meier FA, Zarbo RJ, et al. J Clin Oncol. 2006;24:2808-2814.

COMMENTARY

ISMP medication error report analysis.

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

STUDY

Time of day effects on the incidence of anesthetic adverse events.

Wright MC, Phillips-Bute B, Mark JB, et al. Qual Saf Health Care. 2006;15:258-263.

STUDY

Review of the Australian Incident Monitoring System.

Spigelman AD, Swan J. ANZ J Surg. 2005;75:657-661.

FACT SHEET/FAQS

Medication safety issue brief. Counterfeit drug prevention and identification.

American Hospital Association, American Society of Health-System Pharmacists, Hospitals and Health Networks. Hosp Health Netw. August 2005;79.29-30.

STUDY

Outside case review of surgical pathology for referred patients: the impact on patient care.

Swapp RE, Aubry MC, Salomão DR, Cheville JC. Arch Pathol Lab Med. 2013;137:233-240.

COMMENTARY

Time to get off this pig's back?: the human factors aspects of the mismatch between device and real-world knowledge in the health care environment.

Nunnally ME, Bitan Y. J Patient Saf. 2006;2:124-131.

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