AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (19)

•Diagnostic Errors (20)

•Identification Errors (21)

•Discontinuities, Gaps, and Hand-Off Problems (69)

•Medication Safety (342)

•Medical Complications (24)

•Nonsurgical Procedural Complications (2)

•Surgical Complications (21)

•Transfusion Complications (3)

•Psychological and Social Complications (9)

Origin/Sponsor

•Australia and New Zealand (19)

•North America (531)

Resource Types

•Audiovisual (1)

•Book/Report (17)

•Journal Article (547)

•Legislation/Regulation (8)

•Meeting/Conference (4)

•Newspaper/Magazine Article (61)

•Press Release/Announcement (1)

•Special or Theme Issue (8)

•Tools/Toolkit (4)

•Web Resource (8)

Error Types

•Epidemiology of Errors and Adverse Events (165)

•Active Errors (101)

•Latent Errors (49)

•Near Miss (8)

Approach to Improving Safety

•Quality Improvement Strategies (104)

•Legal and Policy Approaches (38)

•Error Reporting and Analysis (116)

•Communication Improvement (91)

•Human Factors Engineering (90)

•Teamwork (24)

•Specialization of Care (22)

•Logistical Approaches (38)

•Culture of Safety (28)

•Technologic Approaches (584)

•Education and Training (52)

Clinical Areas

•Allied Health Services (2)

•Medicine (356)

•Nursing (42)

•Pharmacy (142)

Target Audience
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Information Professionals

Setting of Care

•Hospitals (351)

•Residential Facilities (7)

•Ambulatory Care (84)

•Outpatient Surgery (3)

1 - 20 of 662

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COMMENTARY

Smart pumps: advanced capabilities and continuous quality improvement.

Vanderveen T. Patient Saf Quality Healthc. January/February 2007.

STUDY

Medication administration discrepancies persist despite electronic ordering.

FitzHenry F, Peterson JF, Arrieta M, Waitman LR, Schildcrout JS, Miller RA. J Am Med Inf Assoc. 2007;14:756-764.

STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

STUDY

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The extent and importance of unintended consequences related to computerized provider order entry.

Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH. J Am Med Inform Assoc. 2007;14:415-423.

STUDY

Smartphone use during inpatient attending rounds: prevalence, patterns and potential for distraction.

Katz-Sidlow RJ, Ludwig A, Miller S, Sidlow R. J Hosp Med. 2012;7:595-599.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: a year in review.

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

NEWSPAPER/MAGAZINE ARTICLE

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

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

STUDY

Patient safety event reporting in critical care: a study of three intensive care units.

Harris CB, Krauss MJ, Coopersmith CM, et al. Crit Care Med. 2007;35:1068-1076.

STUDY

Failure to utilize functions of an electronic prescribing system and the subsequent generation of 'technically preventable' computerized alerts.

Baysari MT, Reckmann MH, Li L, Day RO, Westbrook JI. J Am Med Inform Assoc. 2012;19:1003-1010.

STUDY

Supratherapeutic dosing of acetaminophen among hospitalized patients.

Zhou L, Maviglia SM, Mahoney LM, et al. Arch Intern Med. 2012;172:1721-1728.

STUDY

Impact of health information technology on detection of potential adverse drug events at the ordering stage.

Roberts LL, Ward MM, Brokel JM, Wakefield DS, Crandall DK, Conlon P. Am J Health Syst Pharm. 2010;67:1838-1846.

STUDY

The impact of computerized provider order entry on medication errors in a multispecialty group practice.

Devine EB, Hansen RN, Wilson-Norton JL, et al. J Am Med Inform Assoc. 2010;17:78-84.

STUDY

Impact of electronic prescribing in a hospital setting: a process-focused evaluation.

Cunningham TR, Geller ES, Clarke SW. Int J Med Inform. 2008;77:546-554.

STUDY

Intravenous infusion safety technology: return on investment.

Danello SH, Maddox RR, Schaack GJ. Hosp Pharm. 2009;44:680-687, 696.

COMMENTARY

Using incident reporting to improve patient safety: a conceptual model.

Pronovost PJ, Holzmueller CG, Young J, et al. J Patient Saf. 2007;3:27-33.

STUDY

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.

STUDY

Effect of a weight-based prescribing method within an electronic health record on prescribing errors.

Ginzburg R, Barr WB, Harris M, Munshi S. Am J Health Syst Pharm. 2009;66:2037-2041.

BOOK/REPORT

Building a Better Delivery System: A New Engineering/Health Care Partnership.

Reid PP, Compton WD, Grossman JH, Fanjiang G, eds. Committee on Engineering and the Health Care System. Washington, DC: The National Academies Press; 2005. ISBN: 030909643X.

COMMENTARY

Implementation of a telepharmacy service to provide round-the-clock medication order review by pharmacists.

Wakefield DS, Ward MM, Loes JL, O'Brien J, Sperry L. Am J Health Syst Pharm. 2010;67:2052-2057.

NEWSPAPER/MAGAZINE ARTICLE

Another tragic parenteral nutrition compounding error.

ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.

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