AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (17)

•Diagnostic Errors (12)

•Identification Errors (18)

•Discontinuities, Gaps, and Hand-Off Problems (60)

•Medication Safety (286)

•Medical Complications (19)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (16)

•Transfusion Complications (3)

•Psychological and Social Complications (6)

Origin/Sponsor

•Australia and New Zealand (16)

•North America (403)

Resource Types

•Audiovisual (2)

•Book/Report (15)

•Journal Article (431)

•Legislation/Regulation (6)

•Meeting/Conference (2)

•Newspaper/Magazine Article (51)

•Press Release/Announcement (1)

•Special or Theme Issue (5)

•Tools/Toolkit (3)

•Web Resource (6)

Error Types

•Epidemiology of Errors and Adverse Events (168)

•Active Errors (92)

•Latent Errors (49)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (75)

•Legal and Policy Approaches (30)

•Error Reporting and Analysis (101)

•Communication Improvement (70)

•Human Factors Engineering (77)

•Teamwork (17)

•Specialization of Care (16)

•Logistical Approaches (26)

•Culture of Safety (24)

•Technologic Approaches (461)

•Education and Training (43)

Clinical Areas

•Allied Health Services (1)

•Medicine (304)

•Nursing (33)

•Pharmacy (114)

Target Audience
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Information Professionals

Setting of Care

•Hospitals (319)

•Residential Facilities (5)

•Ambulatory Care (67)

•Outpatient Surgery (2)

1 - 20 of 524

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COMMENTARY

Smart pumps: advanced capabilities and continuous quality improvement.

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

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.

MEASUREMENT TOOL/INDICATOR

Medication Safety Self Assessment for Automated Dispensing Cabinets.

Horsham, PA: Institute for Safe Medication Practices; 2009.

STUDY

Predictive combinations of monitor alarms preceding in-hospital code blue events.

Hu X, Sapo M, Nenov V, et al. J Biomed Inform. 2012;45:913-921.

NEWSPAPER/MAGAZINE ARTICLE

Piecing together medication administration.

Anderson HJ. Health Data Manage. May 1, 2009;17:22.

STUDY

Relationship between medication event rates and the Leapfrog computerized physician order entry evaluation tool.

Leung AA, Keohane C, Lipsitz S, et al. J Am Med Inform Assoc. 2013;20:e85-e90.

STUDY

Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the United States.

Bonis PA, Pickens GT, Rind DM, Foster DA. Int J Med Inform. 2008;77:745-753.

NEWSPAPER/MAGAZINE ARTICLE

Computer viruses are "rampant" on medical devices in hospitals.

Talbot D. MIT Technology Review. October 17, 2012.

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.

REVIEW

The efficacy of computer-enabled discharge communication interventions: a systematic review.

Motamedi SM, Posadas-Calleja J, Straus S, et al. BMJ Qual Saf. 2011;20:403-415.

STUDY

Reported medication errors after introducing an electronic medication management system.

Redley B, Botti M. J Clin Nurs. 2013;22:579-589.

FACT SHEET/FAQS

Bar-Coded Medication Administration (BCMA).

Decisionmaker Brief. AHRQ Publication No: 08-0085, August 2008. Agency for Healthcare Research and Quality, Rockville, MD.

STUDY

The safety of electronic prescribing: manifestations, mechanisms, and rates of system-related errors associated with two commercial systems in hospitals.

Westbrook JI, Baysari MT, Li L, Burke R, Richardson KL, Day RO. J Am Med Inform Assoc. 2013 May 30; [Epub ahead of print].

REVIEW

Prescribing errors in hospital practice.

Tully MP. Br J Clin Pharmacol. 2012;74:668-675.

NEWSPAPER/MAGAZINE ARTICLE

CPOE: it don't come easy.

Anderson HJ. Health Data Manag. January 1, 2009;17:18.

NEWSPAPER/MAGAZINE ARTICLE

"Plug and Play" hospitals: medical devices that exchange data could make hospitals safer.

Grifantini K. Technol Rev. July 9, 2008.

REVIEW

Bar code technology and medication administration error.

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

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.

STUDY

Design and implementation of an automated email notification system for results of tests pending at discharge.

Dalal AK, Schnipper JL, Poon EG, et al. J Am Med Inform Assoc. 2012;19:523-538.

BOOK/REPORT

Inpatient Computerized Provider Order Entry: Findings from the AHRQ Health IT Portfolio.

Dixon BE, Zafar A, for AHRQ National Resource Center for Health IT. Rockville, MD: Agency for Healthcare Research and Quality; January 2009. AHRQ Publication No. 09-0031-EF.

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