AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (44)

•Diagnostic Errors (61)

•Identification Errors (31)

•Discontinuities, Gaps, and Hand-Off Problems (88)

•Fatigue and Sleep Deprivation (44)

•Medication Safety (253)

•Medical Complications (59)

•Nonsurgical Procedural Complications (31)

•Surgical Complications (115)

•Transfusion Complications (5)

•Psychological and Social Complications (24)

Origin/Sponsor

•Asia (22)

•Australia and New Zealand (25)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (660)

•Legislation/Regulation (9)

•Meeting/Conference (2)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (68)

•Press Release/Announcement (14)

•Special or Theme Issue (6)

•Tools/Toolkit (6)

•Web Resource (6)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (270)

•Active Errors (145)

•Latent Errors (47)

•Near Miss (26)

Approach to Improving Safety

•Quality Improvement Strategies (181)

•Legal and Policy Approaches (96)

•Error Reporting and Analysis (355)

•Communication Improvement (155)

•Human Factors Engineering (116)

•Teamwork (41)

•Specialization of Care (32)

•Logistical Approaches (72)

•Culture of Safety (65)

•Technologic Approaches (116)

•Education and Training (93)

Clinical Areas

•Allied Health Services (2)

•Medicine (540)

•Nursing (45)

•Pharmacy (84)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (437)

•Psychiatric Facilities (4)

•Residential Facilities (10)

•Ambulatory Care (51)

•Outpatient Surgery (11)

•Patient Transport (10)

1 - 20 of 811

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NEWSPAPER/MAGAZINE ARTICLE

Manic for medication safety: bar codes and drug information databases are helping to reduce medication errors.

Rogoski RR. Health Manage Technol. February 2007;28:14, 16-18.

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.

AUDIOVISUAL

Preventing fatal heparin overdoses.

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

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.

STUDY

Expanding what we know about off-peak mortality in hospitals.

Hamilton P, Mathur S, Gemeinhardt G, Eschiti V, Campbell M. J Nurs Admin. 2010;40:124-128.

STUDY

Detection and prevention of medication errors using real-time bedside nurse charting.

Nelson NC, Evans RS, Samore MH, Gardner RM. J Am Med Inform Assoc. 2005;12:390-397.

NEWSPAPER/MAGAZINE ARTICLE

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

Meisel Z. Slate. November 8, 2005.

STUDY

How long and how much are nurses now working?

Trinkoff A, Geiger-Brown J, Brady B, Lipscomb J, Muntaner C. Am J Nurs. April 2006;106:60-71.

STUDY

Hospital staff nurses' shift length associated with safety and quality of care.

Stimpfel AW, Aiken LH. J Nurs Care Qual. 2013;28:122-129.

NEWSPAPER/MAGAZINE ARTICLE

ISMP 2007 survey on high-alert medications. Differences between nursing and pharmacy perspectives still prevalent.

ISMP Medication Safety Alert! Acute Care Edition. May 17, 2007;12:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Safety still compromised by computer weaknesses.

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

STUDY

Self-reported violations during medication administration in two paediatric hospitals.

Alper SJ, Holden RJ, Scanlon MC, et al. BMJ Qual Saf. 2012;21:408-415.

NEWSPAPER/MAGAZINE ARTICLE

Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups?

ISMP Medication Safety Alert! Acute Care Edition. May 21, 2009;14:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Scanning out medication errors: Ohio Valley Hospital's automated IV system provides real-time access to patient data.

Carbasho T. Pittsburgh Business Times. April 25, 2005.

FACT SHEET/FAQS

Medication safety issue brief. Bar code implementation strategies.

American Hospital Association, American Society of Health-System Pharmacists, Hospitals and Health Networks. Hosp Health Netw. July 2005;79:65-66.

COMMENTARY

Crossed Coverage

Kayser SR. AHRQ WebM&M [serial online]. February 2007.

STUDY

Patient self-medication--a change in hospital practice.

Grantham G, McMillan V, Dunn SV, Gassner LA, Woodcock P. J Clin Nurs. 2006;15:962-970.

COMMENTARY

ISMP medication error report analysis.

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

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

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.

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