AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (1)

•Diagnostic Errors (12)

•Identification Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (43)

•Medication Safety (117)

•Medical Complications (24)

•Surgical Complications (6)

•Transfusion Complications (1)

•Psychological and Social Complications (7)

Origin/Sponsor

•Australia and New Zealand (5)

•North America (154)

Resource Types

•Audiovisual (1)

•Book/Report (4)

•Clinical Guideline (2)

•Journal Article (170)

•Legislation/Regulation (1)

•Meeting/Conference (1)

•Newspaper/Magazine Article (10)

•Special or Theme Issue (1)

•Tools/Toolkit (4)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (80)

•Active Errors (34)

•Latent Errors (14)

•Near Miss (2)

Approach to Improving Safety

•Quality Improvement Strategies (42)

•Legal and Policy Approaches (13)

•Error Reporting and Analysis (40)

•Communication Improvement (69)

•Human Factors Engineering (14)

•Teamwork (4)

•Specialization of Care (14)

•Logistical Approaches (11)

•Culture of Safety (26)

•Technologic Approaches (37)

•Education and Training (33)

Clinical Areas
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Geriatrics

Target Audience

•Health Care Providers (154)

•Health Care Executives and Administrators (132)

•Non-Health Care Professionals (40)

•Patients (10)

Setting of Care

•Hospitals (78)

•Psychiatric Facilities (2)

•Residential Facilities (82)

•Ambulatory Care (46)

•Patient Transport (1)

1 - 20 of 200

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STUDY

Medication errors during patient transitions into nursing homes: characteristics and association with patient harm.

Desai R, Williams CE, Greene SB, Pierson S, Hansen RA. Am J Geriatr Pharmacother. 2011;9:413-422.

STUDY

Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality improvement opportunities.

Hansen RA, Cornell PY, Ryan PB, Williams CE, Pierson S, Greene SB. Pharmacoepidemiol Drug Saf. 2010;19:1087-1094.

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

Does incorporating medications in the surveyors' interpretive guidelines reduce the use of potentially inappropriate medications in nursing homes?

Lapane KL, Hughes CM, Quilliam BJ. J Am Geriatr Soc. 2007;55:666-673.

STUDY

Medication safety teams' guided implementation of electronic medication administration records in five nursing homes.

Scott-Cawiezell J, Madsen RW, Pepper GA, Vogelsmeier A, Petroski G, Zellmer D. Jt Comm J Qual Patient Saf. 2009;35:29-35.

STUDY

Assessing resident safety culture in nursing homes: using the nursing home survey on resident safety.

Castle NG, Wagner LM, Perera S, Ferguson JC, Handler SM. J Patient Saf. 2010;6:59-67.

STUDY

Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes.

Lapane KL, Hughes CM, Daiello LA, Cameron KA, Feinberg J. J Am Geriatr Soc. 2011;59:1238-1245.

REVIEW

Care transitions and home health care.

Boling PA. Clin Geriatr Med. 2009;25:135-148.

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

Preventing medication errors in long-term care: results and evaluation of a large scale web-based error reporting system.

Pierson S, Hansen R, Greene S, Williams C, Akers R, Jonsson M, Carey T. Qual Saf Health Care. 2007;16:297-302.

STUDY

Barriers and facilitators to communicating nursing errors in long-term care settings.

Wagner LM, Damianakis T, Pho L, Tourangeau A. J Patient Saf. 2013;9:1-7.

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

Repeat medication errors in nursing homes: contributing factors and their association with patient harm.

Crespin DJ, Modi AV, Wei D, et al. Am J Geriatr Pharmacother. 2010;8:258-270.

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.

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

Risk of medication errors at hospital discharge and barriers to problem resolution.

Enguidanos SM, Brumley RD. Home Health Care Serv Q. 2005;24:123-135.

STUDY

Computerized physician order entry with clinical decision support in the long-term care setting: insights from the Baycrest Centre for Geriatric Care.

Rochon PA, Field TS, Bates DW, et al. J Am Geriatr Soc. 2005;53:1780-1789.

COMMENTARY

Defining patient safety in hospice: principles to guide measurement and public reporting.

Casarett D, Spence C, Clark MA, Shield R, Teno JM. J Palliat Med. 2012;15:1120-1123.

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