AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (88)

•Diagnostic Errors (114)

•Identification Errors (65)

•Discontinuities, Gaps, and Hand-Off Problems (197)

•Fatigue and Sleep Deprivation (16)

•Medication Safety (662)

•Medical Complications (225)

•Nonsurgical Procedural Complications (62)

•Surgical Complications (229)

•Transfusion Complications (12)

•Psychological and Social Complications (29)

Origin/Sponsor

•Australia and New Zealand (134)

•Central and South America (6)

•Europe (301)

•North America (1176)

Resource Types

•Audiovisual (4)

•Book/Report (47)

•Clinical Guideline (3)

•Journal Article (1416)

•Legislation/Regulation (24)

•Meeting/Conference (9)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (77)

•Press Release/Announcement (15)

•Special or Theme Issue (19)

•Tools/Toolkit (15)

•Web Resource (28)

Error Types

•Epidemiology of Errors and Adverse Events (515)

•Active Errors (367)

•Latent Errors (104)

•Near Miss (37)

Approach to Improving Safety

•Quality Improvement Strategies (448)

•Legal and Policy Approaches (74)

•Error Reporting and Analysis (453)

•Communication Improvement (412)

•Human Factors Engineering (287)

•Teamwork (150)

•Specialization of Care (123)

•Logistical Approaches (96)

•Culture of Safety (146)

•Technologic Approaches (420)

•Education and Training (296)

Clinical Areas

•Allied Health Services (4)

•Dentistry (3)

•Medicine (1222)

•Nursing (133)

•Pharmacy (207)

Target Audience
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Quality and Safety Professionals

Setting of Care

•Hospitals (1092)

•Psychiatric Facilities (6)

•Residential Facilities (31)

•Ambulatory Care (143)

•Outpatient Surgery (15)

•Patient Transport (17)

1 - 20 of 1668

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REVIEW

Year in review: medication mishaps in the elderly.

Peron EP, Marcum ZA, Boyce R, Hanlon JT, Handler SM. Am J Geriatr Pharmacother. 2011;9:1-10.

COMMENTARY

A Mid-Summer Fog

Braddock CH. AHRQ WebM&M [serial online]. November 2008.

STUDY

Critical drug–drug interactions for use in electronic health records systems with computerized physician order entry: review of leading approaches.

Classen DC, Phansalkar S, Bates DW. J Patient Saf. 2011;7:61-65.

STUDY

An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies.

Palchuk MB, Fang EA, Cygielnik JM, et al. J Am Med Inform Assoc. 2010;17:472-476.

STUDY

Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting.

Gurwitz JH, Field TS, Rochon P, et al. J Am Geriatr Soc. 2008;56:2225-2233.

STUDY

Comparison of methods for identifying patients at risk of medication-related harm.

van Doormaal JE, Rommers MK, Kosterink JGW, Teepe-Twiss IM, Haaijer-Ruskamp FM, Mol PGM. Qual Saf Health Care. 2010;19:e26.

CLINICAL GUIDELINE classic

classic

Medication errors in acute cardiovascular and stroke patients. A scientific statement from the American Heart Association.

Michaels AD, Spinler SA, Leeper B, et al; American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology, Council on Quality of Care and Outcomes Research, Council on Cardiopulmonary, Critical Care, Perioperative, and Resuscitation, Council on Cardiovascular Nursing, Stroke Council. Circulation. 2010;121:1664-1682.

STUDY

Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents.

Redwood S, Rajakumar A, Hodson J, Coleman JJ. BMC Med Inform Decis Mak. 2011;11:29.

REVIEW

Decision support and patient safety: the time has come.

Hasley SK. Am J Obstet Gynecol. 2011;204:461-465.

STUDY

classic

Automated identification of postoperative complications within an electronic medical record using natural language processing.

Murff HJ, FitzHenry F, Matheny ME, et al. JAMA. 2011;306:848-855.

STUDY

Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.

Lee JY, Leblanc K, Fernandes OA, et al. Ann Pharmacother. 2010;44:1887-1895.

STUDY

Utilising improvement science methods to optimise medication reconciliation.

White CM, Schoettker PJ, Conway PH, et al. BMJ Qual Saf. 2011;20:372-380.

STUDY

Adverse drug event rates in six community hospitals and the potential impact of computerized physician order entry for prevention.

Hug BL, Witkowski DJ, Sox CM, et al. J Gen Intern Med. 2010;25:31-38.

STUDY

Horus meets Nightingale in the modern age: how nursing communicates with pharmacy in HCIT era.

Armstrong I, Cox MA. Stud Health Technol Inform. 2006;122:585-586.

STUDY

Medication errors with electronic prescribing (eP): two views of the same picture.

Savage I, Cornford T, Klecun E, Barber N, Clifford S, Franklin BD. BMC Health Serv Res. 2010;10:135.

STUDY

Effects of CPOE on provider cognitive workload: a randomized crossover trial.

Avansino J, Leu MG. Pediatrics. 2012;130:e547-e552.

STUDY

Physician order entry or nurse order entry? Comparison of two implementation strategies for a computerized order entry system aimed at reducing dosing medication errors.

Kazemi A, Fors UG, Tofighi S, Tessma M, Ellenius J. J Med Internet Res. 2010;12:e5.

STUDY

Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy.

Waitman LR, Phillips IE, McCoy AB, et al. Jt Comm J Qual Patient Saf. 2011;37:326-332.

NEWSPAPER/MAGAZINE ARTICLE

Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.

ISMP Medication Safety Alert! Acute Care Edition. August 26, 2010;15:1-3.

STUDY

The influence that electronic prescribing has on medication errors and preventable adverse drug events: an interrupted time-series study.

van Doormaal JE, van den Bemt PMLA, Zaal RJ, et al. J Am Med Inform Assoc. 2009;16:816-825.

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