AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (3)

•Diagnostic Errors (33)

•Identification Errors (4)

•Discontinuities, Gaps, and Hand-Off Problems (48)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (96)

•Medical Complications (9)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (1)

•Psychological and Social Complications (12)

Origin/Sponsor

•Australia and New Zealand (8)

•North America (161)

Resource Types

•Audiovisual (3)

•Book/Report (11)

•Clinical Guideline (1)

•Journal Article (212)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (8)

•Tools/Toolkit (6)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (73)

•Active Errors (41)

•Latent Errors (7)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (53)

•Legal and Policy Approaches (17)

•Error Reporting and Analysis (72)

•Communication Improvement (87)

•Human Factors Engineering (11)

•Teamwork (20)

•Specialization of Care (7)

•Logistical Approaches (18)

•Culture of Safety (21)

•Technologic Approaches (71)

•Education and Training (41)

Clinical Areas
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Primary Care

Target Audience

•Health Care Providers (180)

•Health Care Executives and Administrators (144)

•Non-Health Care Professionals (100)

•Patients (10)

Setting of Care

•Hospitals (35)

•Psychiatric Facilities (2)

•Residential Facilities (2)

•Ambulatory Care (196)

1 - 20 of 244

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STUDY

Frequency of risk factors that potentially increase harm from medications in older adults receiving primary care.

McCarthy L, Dolovich L, Haq M, Thabane L, Kaczorowski J. Can J Clin Pharmacol. 2007;14:e283-e290.

STUDY

Clinical outcomes from the use of Medication Report when elderly patients are discharged from hospital.

Midlöv P, Deierborg E, Holmdahl L, Höglund P, Eriksson T. Pharm World Sci. 2008;30:840-845.

STUDY

Diagramming patients' views of root causes of adverse drug events in ambulatory care: an online tool for planning education and research.

Brown M, Frost R, Ko Y, Woosley R. Patient Educ Couns. 2006;62:302-315.

STUDY

Improving medication reconciliation in the outpatient setting.

Varkey P, Cunningham J, Bisping S. Jt Comm J Qual Patient Saf. 2007;33:286-292.

STUDY

Pharmacist-supported medication review training for general practitioners: feasibility and acceptability.

Krska J, Gill D, Hansford D. Med Educ. 2006;40:1217-1225.

GRANT RECIPIENT

AHRQ Risk-informed Intervention Development and Implementation of Safe Practices in Ambulatory Care.

Rockville, MD: Agency for Healthcare Research and Quality; October 2008.

STUDY

In-home medication reviews: a novel approach to improving patient care through coordination of care.

Willis JS, Hoy RH, Jenkins WD. J Community Health. 2011;36:1027-1031.

STUDY

Post-discharge medication reviews for patients with heart failure: a pilot study.

Ponniah A, Shakib S, Doecke CJ, Boyce M, Angley M. Pharm World Sci. 2008;30:810-815.

STUDY

Sources and types of discrepancies between electronic medical records and actual outpatient medication use.

Orrico KB. J Manag Care Pharm. 2008;14:626-631.

STUDY

Physician patient communication failure facilitates medication errors in older polymedicated patients with multiple comorbidities.

Mira JJ, Orozco-Beltrán D, Pérez-Jover V, et al. Fam Pract. 2013;30:56-63.

STUDY

An effort to improve electronic health record medication list accuracy between visits: patients' and physicians' response.

Staroselsky M, Volk LA, Tsurikova R, et al. Int J Med Inform. 2008;77:153-160.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety records: silent witness.

Gould M. Health Service Journal. September 15, 2008:22-24.

TOOLKIT

Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation.

Gleason KM, Brake H, Agramonte V, Perfetti C. Rockville, MD: Agency for Healthcare Research and Quality; Revised August 2012. AHRQ Publication No. 11(12)-0059.

STUDY

Identifying discrepancies in electronic medical records through pharmacist medication reconciliation.

Stewart AL, Lynch KJ. J Am Pharm Assoc (2003). 2012;52:59-66.

STUDY

Bayesian cohort and cross-sectional analyses of the PINCER trial: a pharmacist-led intervention to reduce medication errors in primary care.

Hemming K, Chilton PJ, Lilford RJ, Avery A, Sheikh A. PLoS ONE. 2012;7:e38306.

STUDY

Usability of a computerised drug monitoring programme to detect adverse drug events and non-compliance in outpatient ambulatory care.

Auger C, Forster AJ, Oake N, Tamblyn R. BMJ Qual Saf. 2013;22:306-316.

STUDY

Retail pharmacy staff perceptions of design strengths and weaknesses of electronic prescribing.

Odukoya O, Chui MA. J Am Med Inform Assoc. 2012;19:1059-1065.

STUDY

Multidisciplinary approach to inpatient medication reconciliation in an academic setting.

Varkey P, Cunningham J, O'Meara J, Bonacci R, Desai N, Sheeler R. Am J Health Syst Pharm. 2007;64:850-854.

STUDY

Problems after discharge and understanding of communication with their primary care physicians (PCPs) among hospitalized seniors: a mixed methods study.

Arora VM, Prochaska ML, Farnan JM, et al. J Hosp Med. 2010;5:385-391.

STUDY

Alternatives to potentially inappropriate medications for use in e-prescribing software: triggers and treatment algorithms.

Hume AL, Quilliam BJ, Goldman R, Eaton C, Lapane KL. BMJ Qual Saf. 2011;20:875-884.

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