AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (51)

•Diagnostic Errors (37)

•Identification Errors (27)

•Discontinuities, Gaps, and Hand-Off Problems (235)

•Fatigue and Sleep Deprivation (33)

•Medication Safety (344)

•Medical Complications (228)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (68)

•Transfusion Complications (9)

•Psychological and Social Complications (59)

Origin/Sponsor

•Australia and New Zealand (42)

•Europe (236)

•North America (1103)

Resource Types

•Audiovisual (19)

•Book/Report (111)

•Clinical Guideline (1)

•Journal Article (1006)

•Legislation/Regulation (11)

•Meeting/Conference (6)

•Newspaper/Magazine Article (173)

•Press Release/Announcement (2)

•Special or Theme Issue (11)

•Tools/Toolkit (24)

•Web Resource (27)

Error Types

•Epidemiology of Errors and Adverse Events (375)

•Active Errors (157)

•Latent Errors (95)

•Near Miss (18)

Approach to Improving Safety

•Quality Improvement Strategies (353)

•Legal and Policy Approaches (165)

•Error Reporting and Analysis (390)

•Communication Improvement (374)

•Human Factors Engineering (138)

•Teamwork (94)

•Specialization of Care (102)

•Logistical Approaches (111)

•Culture of Safety (245)

•Technologic Approaches (243)

•Education and Training (250)

Clinical Areas
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General Internal Medicine

Target Audience

•Health Care Providers (793)

•Health Care Executives and Administrators (1121)

•Non-Health Care Professionals (550)

•Patients (122)

Setting of Care

•Hospitals (1253)

•Psychiatric Facilities (4)

•Residential Facilities (8)

•Ambulatory Care (148)

•Outpatient Surgery (4)

•Patient Transport (2)

1 - 20 of 1399

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STUDY

Intravenous infusion safety technology: return on investment.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Cause for concern: drug shortages disrupt operations, tax hospitalists' treatment patterns.

Collins TR. The Hospitalist. July 2011.

NEWSPAPER/MAGAZINE ARTICLE

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

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.

ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.

STUDY

The unintended consequences of computerized provider order entry: findings from a mixed methods exploration.

Ash JS, Sittig DF, Dykstra R, Campbell E, Guappone K. Int J Med Inform. 2009;78(suppl 1): S69-S76.

MEASUREMENT TOOL/INDICATOR

Medication Safety Self Assessment for Automated Dispensing Cabinets.

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

COMMENTARY

Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps.

Greenwald JL, Halasyamani L, Greene J, et al. J Hosp Med. 2010;5:477-485.

REVIEW

Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002-2008.

Roughead EE, Semple SJ. Aust New Zealand Health Policy. 2009;6:18.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

NEWSPAPER/MAGAZINE ARTICLE

For all the right reasons.

Hagland M. Healthc Informatics. 2009;26:40-44.

NEWSPAPER/MAGAZINE ARTICLE

Effective use of medication-related decision support in CPOE.

Metzger JB, Welebob E, Turisco F, Classen DC. Patient Saf Qual Healthc. Sept/Oct 2008;5:16-24.

MEASUREMENT TOOL/INDICATOR

2011 ISMP Medication Safety Self Assessment for Hospitals.

Horsham, PA: Institute for Safe Medication Practices; April 2011.

NEWSPAPER/MAGAZINE ARTICLE

Safe practice environment chapter proposed by USP.

ISMP Medication Safety Alert! Acute Care Edition. December 4, 2008;13:1-3.

REVIEW

Medication safety in acute care in Australia: where are we now? Part 2: a review of strategies and activities for improving medication safety 2002-2008.

Semple SJ, Roughead EE. Aust New Zealand Health Policy. 2009;6:24.

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.

NEWSPAPER/MAGAZINE ARTICLE

Piecing together medication administration.

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

NEWSPAPER/MAGAZINE ARTICLE

How has the current economy affected patient safety?

ISMP Medication Safety Alert! Acute Care Edition. September 10, 2009;14:1-2.

NEWSPAPER/MAGAZINE ARTICLE

Perfect is possible.

Berwick DM, Leape LL. Newsweek. October 16, 2006:70-71.

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