AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (45)

•Diagnostic Errors (54)

•Identification Errors (30)

•Discontinuities, Gaps, and Hand-Off Problems (71)

•Fatigue and Sleep Deprivation (33)

•Medication Safety (235)

•Medical Complications (59)

•Nonsurgical Procedural Complications (30)

•Surgical Complications (114)

•Transfusion Complications (5)

•Psychological and Social Complications (21)

Origin/Sponsor

•Asia (21)

•Australia and New Zealand (27)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (614)

•Legislation/Regulation (7)

•Meeting/Conference (1)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (56)

•Press Release/Announcement (16)

•Special or Theme Issue (6)

•Tools/Toolkit (6)

•Web Resource (6)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (269)

•Active Errors (138)

•Latent Errors (46)

•Near Miss (24)

Approach to Improving Safety

•Quality Improvement Strategies (170)

•Legal and Policy Approaches (73)

•Error Reporting and Analysis (360)

•Communication Improvement (129)

•Human Factors Engineering (109)

•Teamwork (39)

•Specialization of Care (31)

•Logistical Approaches (52)

•Culture of Safety (54)

•Technologic Approaches (102)

•Education and Training (80)

Clinical Areas

•Allied Health Services (3)

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Risk Managers

Setting of Care

•Hospitals (417)

•Psychiatric Facilities (5)

•Residential Facilities (11)

•Ambulatory Care (45)

•Outpatient Surgery (11)

•Patient Transport (10)

1 - 20 of 750

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STUDY

Review of the Australian Incident Monitoring System.

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

STUDY

Antiretroviral medication errors among hospitalized patients with HIV infection.

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

BOOK/REPORT

With Safety in Mind: Mental Health Services and Patient Safety.

Scobie S, Minghella E, Dale C, Thomson R, Lelliott P, Hill K. London, UK: National Patient Safety Agency; July 2006.

STUDY

Patient notification for bloodborne pathogen testing due to unsafe injection practices in the US health care settings, 2001–2011.

Guh AY, Thompson ND, Schaefer MK, Patel PR, Perz JF. Med Care. 2012;50:785-791.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010:45;352-355.

STUDY

Computer based medication error reporting: insights and implications.

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

STUDY

Evaluation of inpatient admissions and potential antimicrobial and analgesic dosing errors in overweight children.

Miller JL, Johnson PN, Harrison DL, Hagemann TM. Ann Pharmacother. 2010;44:35-42.

STUDY

Interruptions during the delivery of high-risk medications.

Trbovich P, Prakash V, Stewart J, Trip K, Savage P. J Nurs Adm. 2010;40:211-218.

STUDY

Towards safer neonatal transfer: the importance of critical incident review.

Moss SJ, Embleton ND, Fenton AC. Arch Dis Child. 2005;90:729-732.

STUDY

An overview of intravenous-related medication administration errors as reported to MEDMARX^(R), a national medication error-reporting program.

Hicks RW, Becker SC. J Infus Nurs. 2006;29:20-27.

REVIEW

Understanding factors that impact on health care professionals' risk perceptions and responses toward Clostridium difficile and methicillin-resistant Staphylococcus aureus: a structured literature review.

Burnett E, Kearney N, Johnston B, Corlett J, Macgillivray S. Am J Infect Control. 2013;41:394-400.

PRESS RELEASE/ANNOUNCEMENT

Serious medication errors from intravenous administration of nimodipine oral capsules.

MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; August 2, 2010.

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

Adverse drug event reporting in intensive care units: a survey of current practices.

Kane-Gill SL, Devlin JW. Ann Pharmacother. 2006;40:1267-73.

STUDY

Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children.

Uppal N, Yasseen B, Seto W, Parshuram CS. CMAJ. 2011;183:E246-E248.

STUDY

Rework and workarounds in nurse medication administration process: implications for work processes and patient safety.

Halbesleben JRB, Savage GT, Wakefield DS, Wakefield BJ. Health Care Manage Rev. 2010;35:124-133.

REVIEW

Nature of human error: implications for surgical practice.

Cuschieri A. Ann Surg. 2006;244:642-648.

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.

STUDY

A systematic approach to the identification and classification of near-miss events on labor and delivery in a large, national health care system.

Clark SL, Meyers JA, Frye DR, McManus K, Perlin JB. Am J Obstet Gynecol. 2012;207:441-445.

NEWSPAPER/MAGAZINE ARTICLE

Ding-a-ling-a-ling: ambulances can be dangerous places.

Meisel Z. Slate. November 8, 2005.

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