AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (18)

•Diagnostic Errors (19)

•Identification Errors (20)

•Discontinuities, Gaps, and Hand-Off Problems (63)

•Medication Safety (319)

•Medical Complications (25)

•Nonsurgical Procedural Complications (2)

•Surgical Complications (20)

•Transfusion Complications (3)

•Psychological and Social Complications (9)

Origin/Sponsor

•Australia and New Zealand (16)

•North America (513)

Resource Types

•Audiovisual (1)

•Book/Report (16)

•Journal Article (511)

•Legislation/Regulation (8)

•Meeting/Conference (2)

•Newspaper/Magazine Article (59)

•Special or Theme Issue (8)

•Tools/Toolkit (3)

•Web Resource (6)

Error Types

•Epidemiology of Errors and Adverse Events (154)

•Active Errors (98)

•Latent Errors (49)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (102)

•Legal and Policy Approaches (37)

•Error Reporting and Analysis (102)

•Communication Improvement (84)

•Human Factors Engineering (86)

•Teamwork (25)

•Specialization of Care (17)

•Logistical Approaches (35)

•Culture of Safety (24)

•Technologic Approaches (546)

•Education and Training (48)

Clinical Areas

•Allied Health Services (2)

•Medicine (334)

•Nursing (42)

•Pharmacy (128)

Target Audience
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Information Professionals

Setting of Care

•Hospitals (325)

•Residential Facilities (6)

•Ambulatory Care (77)

•Outpatient Surgery (3)

1 - 20 of 615

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NEWSPAPER/MAGAZINE ARTICLE

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

STUDY

Medication-error alerts for warfarin orders detected by a bar-code-assisted medication administration system.

Fitzhenry F, Doran J, Lobo B, et al. Am J Health Syst Pharm. 2011;68:434-441.

STUDY

Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study.

Morriss FH Jr, Abramowitz PW, Nelson SP, et al. J Pediatr. 2009;197:678-685.

REVIEW

Informatics confronts drug–drug interactions.

Percha B, Altman RB. Trends Pharmacol Sci. 2013;34:178-184.

STUDY

The use of patient pictures and verification screens to reduce computerized provider order entry errors.

Hyman D, Laire M, Redmond D, Kaplan DW. Pediatrics. 2012;130:e211-e219.

STUDY

Nurse interruptions pre- and post-implementation of a point-of-care medication administration system.

Stamp KD, Willis DG. J Nurs Care Qual. 2010;25:231-239.

STUDY

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.

Staggers N, Clark L, Blaz JW, Kapsandoy S. Health Informatics J. 2011;17:209-223.

NEWSPAPER/MAGAZINE ARTICLE

Design for reliability: barcoded medication administration.

Hayden AC, Lanoue ET, Still CJ. Patient Saf Qual Healthc. July/August 2011;8:12-20.

STUDY

Complexity of medication-related verbal orders.

Wakefield DS, Ward MM, Groath D, et al. Am J Med Qual. 2008;23:7-17.

REVIEW

Bar code technology and medication administration error.

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

STUDY

Evaluation of causes and frequency of medication errors during information technology downtime.

Hanuscak TL, Szeinbach SL, Seoane-Vazquez E, Reichert BJ, McCluskey CF. Am J Health Syst Pharm. 2009;66:1119-1124.

STUDY

Bar-code technology for medication administration: medication errors and nurse satisfaction.

Fowler SB, Sohler P, Zarillo DF. MedSurg Nursing. 2009;18:103-110.

COMMENTARY

Incomplete care—on the trail of flaws in the system.

Gandhi TK, Zuccotti G, Lee TH. N Engl J Med. 2011;365:486-488.

NEWSPAPER/MAGAZINE ARTICLE

Multiple latent failures align to allow a serious drug interaction to harm a patient.

ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Scanner beep only means the barcode has been scanned.

ISMP Medication Safety Alert! Acute Care Edition. June 30, 2011;16:1-2.

COMMENTARY

Latency of ECG displays of hospital telemetry systems: a science advisory from the American Heart Association.

Turakhia MP, Estes NA 3rd, Drew BJ, et al; Electrocardiography and Arrhythmias Committee of the American Heart Association Council on Clinical Cardiology and Council on Cardiovascular Nursing. Circulation. 2012;126:1665-1669.

STUDY

Paper- and computer-based workarounds to electronic health record use at three benchmark institutions.

Flanagan ME, Saleem JJ, Millitello LG, Russ AL, Doebbeling BN. J Am Med Inform Assoc. 2013 Mar 14; [Epub ahead of print].

NEWSPAPER/MAGAZINE ARTICLE

Barcode technology flaws put some patients at risk.

US News & World Report. July 3, 2008.

STUDY

Matching identifiers in electronic health records: implications for duplicate records and patient safety.

McCoy AB, Wright A, Kahn MG, Shapiro JS, Bernstam EV, Sittig DF. BMJ Qual Saf. 2013;22:219-224.

STUDY

Bar code medication administration technology: characterization of high-alert medication triggers and clinician workarounds.

Miller DF, Fortier CR, Garrison KL. Ann Pharmacother. 2011;45:162-168.

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