AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (44)

•Diagnostic Errors (64)

•Identification Errors (32)

•Discontinuities, Gaps, and Hand-Off Problems (82)

•Fatigue and Sleep Deprivation (43)

•Medication Safety (255)

•Medical Complications (60)

•Nonsurgical Procedural Complications (31)

•Surgical Complications (115)

•Transfusion Complications (5)

•Psychological and Social Complications (27)

Origin/Sponsor

•Asia (25)

•Australia and New Zealand (23)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (671)

•Legislation/Regulation (9)

•Meeting/Conference (2)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (67)

•Press Release/Announcement (14)

•Special or Theme Issue (7)

•Tools/Toolkit (6)

•Web Resource (6)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (279)

•Active Errors (151)

•Latent Errors (48)

•Near Miss (25)

Approach to Improving Safety

•Quality Improvement Strategies (184)

•Legal and Policy Approaches (99)

•Error Reporting and Analysis (366)

•Communication Improvement (150)

•Human Factors Engineering (116)

•Teamwork (39)

•Specialization of Care (33)

•Logistical Approaches (68)

•Culture of Safety (63)

•Technologic Approaches (117)

•Education and Training (93)

Clinical Areas

•Allied Health Services (2)

•Medicine (549)

•Nursing (38)

•Pharmacy (86)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (454)

•Psychiatric Facilities (1)

•Residential Facilities (11)

•Ambulatory Care (50)

•Outpatient Surgery (12)

•Patient Transport (8)

1 - 20 of 824

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COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

COMMENTARY

Implementation of a specialized pharmacy team to monitor high-risk medications during discharge.

Martin ES III, Overstreet RL, Jackson-Khalil LR, McCollough HL, Meyer TA, Xu Q. Am J Health Syst Pharm. 2013;70:18-21.

STUDY

Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance.

Classen DC, Jaser L, Budnitz DS. Jt Comm J Qual Patient Saf. 2010;36:12-21, AP1-AP9.

STUDY

Medication errors recovered by emergency department pharmacists.

Rothschild JM, Churchill W, Erickson A, et al. Ann Emerg Med. 2010;55:513-521.

NEWSPAPER/MAGAZINE ARTICLE

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.

STUDY

Enhancing medication use safety: benefits of learning from your peers.

Kazandjian VA, Ogunbo S, Wicker KG, Vaida AJ, Pipesh F. Qual Saf Health Care. 2009;18:331-335.

STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

REVIEW

Systematic review of medication safety assessment methods.

Meyer-Massetti C, Cheng CM, Schwappach DL, et al. Am J Health Syst Pharm. 2011;68:227-240.

REVIEW

Bar code technology and medication administration error.

Young J, Slebodnik M, Sands L. J Patient Saf. 2010;6;115-120.

STUDY

The costs of adverse drug events in community hospitals.

Hug BL, Keohane C, Seger DL, Yoon C, Bates DW. Jt Comm J Qual Patient Saf. 2012;38:120-126.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

STUDY

What is the measure of a safe hospital? Medication errors missed by risk management, clinical staff, and surveyors.

Grasso BC, Rothschild JM, Jordan CW, Jayaram G. J Psychiatr Pract. 2005;11:268-273.

STUDY

Medication reconciliation for reducing drug-discrepancy adverse events.

Boockvar KS, Carlson Lacorte H, Giambanco V, Fridman B, Siu A. Am J Geriatr Pharmacother. 2006;4:236-243.

REVIEW

Hospital do-not-resuscitate orders: why they have failed and how to fix them.

Yuen JK, Reid MC, Fetters MD. J Gen Intern Med. 2011;26:791-797.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:13-17.

BOOK/REPORT classic

The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives.

Maxfield D, Grenny J, Lavandero R, Groah L. Provo, UT: VitalSmarts; 2011.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:282-287.

STUDY

An inpatient fall prevention initiative in a tertiary care hospital.

Weinberg J, Proske D, Szerszen A, et al. Jt Comm J Qual Patient Saf. 2011;37:317-325.

STUDY

From research to practice: factors affecting implementation of prospective targeted injury-detection systems.

Sorensen AV, Harrison MI, Kane HL, Roussel AE, Halpern MT, Bernard SL. BMJ Qual Saf. 2011;20:527-533.

BOOK/REPORT

Adverse Events in Hospitals: Methods for Identifying Events.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; March 2010. Report No. OEI-06-08-00221.

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