AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (2)

•Diagnostic Errors (12)

•Identification Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (45)

•Medication Safety (128)

•Medical Complications (26)

•Surgical Complications (6)

•Transfusion Complications (1)

•Psychological and Social Complications (7)

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•Australia and New Zealand (5)

•North America (160)

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•Journal Article (186)

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•Newspaper/Magazine Article (10)

•Special or Theme Issue (2)

•Tools/Toolkit (4)

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Error Types

•Epidemiology of Errors and Adverse Events (90)

•Active Errors (37)

•Latent Errors (15)

•Near Miss (3)

Approach to Improving Safety

•Quality Improvement Strategies (46)

•Legal and Policy Approaches (16)

•Error Reporting and Analysis (49)

•Communication Improvement (71)

•Human Factors Engineering (14)

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•Culture of Safety (26)

•Technologic Approaches (40)

•Education and Training (36)

Clinical Areas
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Geriatrics

Target Audience

•Health Care Providers (163)

•Health Care Executives and Administrators (142)

•Non-Health Care Professionals (45)

•Patients (10)

Setting of Care

•Hospitals (88)

•Psychiatric Facilities (3)

•Residential Facilities (82)

•Ambulatory Care (51)

•Patient Transport (1)

1 - 20 of 219

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REVIEW

Year in review: medication mishaps in the elderly.

Peron EP, Marcum ZA, Boyce R, Hanlon JT, Handler SM. Am J Geriatr Pharmacother. 2011;9:1-10.

STUDY

Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting.

Gurwitz JH, Field TS, Rochon P, et al. J Am Geriatr Soc. 2008;56:2225-2233.

STUDY

Consistency between coded poison center data and fatality abstract narratives for therapeutic error deaths in older adults.

Hayes BD, Klein-Schwartz W. Clin Toxicol (Phila). 2010;48:68-71.

STUDY

classic

Fall prevention in acute care hospitals: a randomized trial.

Dykes PC, Carroll DL, Hurley A, et al. JAMA. 2010;304:1912-1918.

STUDY

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.

STUDY

Medication reconciliation for reducing drug-discrepancy adverse events.

Boockvar KS, Carlson Lacorte H, Giambanco V, Fridman B, Siu A. Am J Geriatr Pharmacother. 2006;4:236-243.

COMMENTARY

Beyond the prescription: medication monitoring and adverse drug events in older adults.

Steinman MA, Handler SM, Gurwitz JH, Schiff GD, Covinsky KE. J Am Geriatr Soc. 2011;59:1513-1520.

STUDY

Adverse drug events in the outpatient setting: an 11-year national analysis.

Bourgeois FT, Shannon MW, Valim C, Mandl KD. Pharmacoepidemiol Drug Saf. 2010;19:901-910.

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

Medication discrepancies upon hospital to skilled nursing facility transitions.

Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. J Gen Intern Med. 2009;24:630-635.

STUDY

Nursing home error and level of staff credentials.

Scott-Cawiezell J, Pepper GA, Madsen RW, Petroski G, Vogelsmeier A, Zellmer D. Clin Nurs Res. 2007;16:72-78.

STUDY

Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system.

Mattison MLP, Afonso KA, Ngo LH, Mukamal KJ. Arch Intern Med. 2010;170:1331-1336.

STUDY

classic

Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients.

Hamilton H, Gallagher P, Ryan C, Byrne S, O’Mahony D. Arch Intern Med. 2011;171:1013-1019.

REVIEW

Epidemiology of medication-related adverse events in nursing homes.

Handler SM, Wright RM, Ruby CM, Hanlon JT. Am J Geriatr Pharmacother. 2006;4:264-272.

STUDY

Medication administration errors in assisted living: scope, characteristics, and the importance of staff training.

Zimmerman S, Love K, Sloane PD, Cohen LW, Reed D, Carder PC; Center for Excellence in Assisted Living-University of North Carolina Collaborative. J Am Geriatr Soc. 2011;59:1060-1068.

STUDY

Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach.

Field TS, Tjia J, Mazor KM, et al. Am J Med. 2011;124:179.e1-179.e7.

STUDY

Polypharmacy in hospitalized older adult cancer patients: experience from a prospective, observational study of an oncology-acute care for elders unit.

Flood KL, Carroll MB, Le CV, Brown CJ. Am J Geriatr Pharmacother. 2009;7:151-158.

STUDY

Quantification and classification of errors associated with hand-repackaging of medications in long-term care facilities in Germany.

Gerber A, Kohaupt I, Lauterbach KW, Buescher G, Stock S, Lungen M. Am J Geriatr Pharmacother. 2008;6:212-219.

STUDY

The effect of medication reconciliation in elderly patients at hospital discharge.

Midlöv P, Bahrani L, Seyfali M, Höglund P, Rickhag E, Eriksson T. Int J Clin Pharm. 2012;34:113-119.

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.

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