AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (91)

•Diagnostic Errors (93)

•Identification Errors (76)

•Discontinuities, Gaps, and Hand-Off Problems (256)

•Fatigue and Sleep Deprivation (45)

•Medication Safety (708)

•Medical Complications (255)

•Nonsurgical Procedural Complications (58)

•Surgical Complications (245)

•Transfusion Complications (9)

•Psychological and Social Complications (58)

Origin/Sponsor

•Australia and New Zealand (52)

•Central and South America (4)

•Europe (218)

•North America (1763)

Resource Types

•Audiovisual (8)

•Book/Report (61)

•Clinical Guideline (2)

•Journal Article (1747)

•Legislation/Regulation (26)

•Meeting/Conference (11)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (124)

•Press Release/Announcement (8)

•Special or Theme Issue (17)

•Tools/Toolkit (18)

•Web Resource (32)

Error Types

•Epidemiology of Errors and Adverse Events (600)

•Active Errors (365)

•Latent Errors (120)

•Near Miss (42)

Approach to Improving Safety

•Quality Improvement Strategies (520)

•Legal and Policy Approaches (101)

•Error Reporting and Analysis (631)

•Communication Improvement (468)

•Human Factors Engineering (311)

•Teamwork (184)

•Specialization of Care (158)

•Logistical Approaches (160)

•Culture of Safety (262)

•Technologic Approaches (402)

•Education and Training (405)

Clinical Areas

•Allied Health Services (6)

•Complementary and Alternative Medicine (1)

•Dentistry (3)

•Medicine (1459)

•Nursing (244)

•Pharmacy (247)

Target Audience
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Quality and Safety Professionals

Setting of Care

•Hospitals (1386)

•Psychiatric Facilities (6)

•Residential Facilities (32)

•Ambulatory Care (166)

•Outpatient Surgery (19)

•Patient Transport (16)

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STUDY

Can surveillance systems identify and avert adverse drug events? A prospective evaluation of a commercial application.

Jha AK, Laguette J, Seger A, Bates DW. J Am Med Inform Assoc. 2008;15:647-653.

STUDY

Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.

Schillig J, Kaatz S, Hudson M, Krol GD, Szandzik EG, Kalus JS. J Hosp Med. 2011;6:322-328.

STUDY

Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.

Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.

STUDY

Evaluating clinical decision support systems: monitoring CPOE order check override rates in the Department of Veterans Affairs' computerized patient record system.

Lin C-P, Payne TH, Nichol WP, et al. J Am Med Inform Assoc. 2008;15:620-626.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors occurring with the use of bar-code administration technology.

PA-PSRS Patient Saf Advis. December 2008;5:122-126.

AUDIOVISUAL PRESENTATION

When things go wrong.

Institute for Healthcare Improvement. Campaign Live. August 18, 2008.

STUDY

Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.

Walker PC, Bernstein SJ, Tucker Jones JN, et al. Arch Intern Med. 2009;169:2003-2010.

COMMENTARY

ISMP medication error report analysis.

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

STUDY

classic

Effect of bar-code technology on the safety of medication administration.

Poon EG, Keohane CA, Yoon CS, et al. N Engl J Med. 2010;362:1698-1707.

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

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

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.

STUDY

Medication errors: how reliable are the severity ratings reported to the National Reporting and Learning System?

Williams SD, Ashcroft DM. Int J Qual Health Care. 2009;21:316-320.

STUDY

classic

Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial.

Kripalani S, Roumie CL, Dalal AK, et al; PILL-CVD (Pharmacist Intervention for Low Literacy in Cardiovascular Disease) Study Group. Ann Intern Med. 2012;157:1-10.

COMMENTARY

A model for medication safety event detection.

Snyder RA, Fields W. Int J Qual Health Care. 2010;22:179-186.

STUDY

Predictive value of alert triggers for identification of developing adverse drug events.

Moore C, Li J, Hung CC, Downs J, Nebeker JR. J Patient Saf. 2009;5:223-228.

NEWSPAPER/MAGAZINE ARTICLE

Collaboration focused on priority issues promotes safety.

ISMP Medication Safety Alert! Acute Care Edition. October 10, 2008;13:1-3.

STUDY

Full implementation of computerized physician order entry and medication-related quality outcomes: a study of 3364 hospitals.

Yu FB, Menachemi N, Berner ES, Allison JJ, Weissman NW, Houston TK. Am J Med Qual. 2009;24:278-286.

NEWSPAPER/MAGAZINE ARTICLE

Shakespeare was on target—don't be a borrower or lender.

ISMP Medication Safety Alert! Acute Care Edition. November 19, 2009;14:1-3.

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.

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