AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (20)

•Diagnostic Errors (8)

•Identification Errors (12)

•Discontinuities, Gaps, and Hand-Off Problems (52)

•Fatigue and Sleep Deprivation (18)

•Medication Safety (210)

•Medical Complications (61)

•Nonsurgical Procedural Complications (13)

•Surgical Complications (30)

•Psychological and Social Complications (29)

Origin/Sponsor

•Asia (16)

•Australia and New Zealand (19)

•Central and South America (1)

Resource Types

•Clinical Guideline (2)

•Journal Article (472)

•Legislation/Regulation (4)

•Meeting/Conference (4)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (36)

•Press Release/Announcement (1)

•Special or Theme Issue (9)

•Tools/Toolkit (4)

•Web Resource (5)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (106)

•Active Errors (110)

•Latent Errors (56)

•Near Miss (19)

Approach to Improving Safety

•Quality Improvement Strategies (95)

•Legal and Policy Approaches (36)

•Error Reporting and Analysis (123)

•Communication Improvement (119)

•Human Factors Engineering (85)

•Teamwork (59)

•Specialization of Care (33)

•Logistical Approaches (94)

•Culture of Safety (88)

•Technologic Approaches (86)

•Education and Training (156)

Clinical Areas
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Nursing

•Medical/Surgical/Psychiatric Nursing (52)

•Critical Care Nursing (39)

•Anesthesia Nursing (8)

•Obstetrical Nursing (4)

•Emergency Nursing (24)

•Home Nursing (6)

Target Audience

•Health Care Providers (468)

•Health Care Executives and Administrators (490)

•Non-Health Care Professionals (194)

•Patients (15)

Setting of Care

•Hospitals (376)

•Psychiatric Facilities (2)

•Residential Facilities (20)

•Ambulatory Care (21)

•Outpatient Surgery (4)

1 - 20 of 555

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COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

COMMENTARY

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43;788-792.

NEWSPAPER/MAGAZINE ARTICLE

Epidural-IV route mix-ups: reducing the risk of deadly errors.

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

STUDY

Medication safety initiative in reducing medication errors.

Nguyen EE, Connolly PM, Wong V. J Nurs Care Qual. 2010;25:224-230.

NEWSPAPER/MAGAZINE ARTICLE

Design for reliability: barcoded medication administration.

Hayden AC, Lanoue ET, Still CJ. Patient Saf Qual Healthc. July/August 2011;8:12-20.

STUDY

Bar-code technology for medication administration: medication errors and nurse satisfaction.

Fowler SB, Sohler P, Zarillo DF. MedSurg Nursing. 2009;18:103-110.

STUDY

The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.

Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. Qual Saf Health Care. 2010;19:430-434.

NEWSPAPER/MAGAZINE ARTICLE

An extra dose of safety.

Health Manage Techol. April 2007;28:30-32, 34.

COMMENTARY

Implementing a safe and reliable process for medication administration.

Richardson B, Bromirski B, Hayden A. Clin Nurse Spec. 2012;26:169-176.

SPECIAL OR THEME ISSUE

Special Issue: Patient Safety.

Ergonomics. 2006;49:439-630.

COMMENTARY classic

Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.

COMMENTARY

Smart pumps: implications for nurse leaders.

Kirkbride G, Vermace B. Nurs Adm Q. 2011;35:110-118.

COMMENTARY

Leading a highly visible hospital through a serious reportable event.

Erickson JI. J Nurs Adm. 2012;42:131-133.

STUDY

Evaluation of a nurse-led safety program in a critical care unit.

Saladino L, Pickett LC, Frush K, Mall A, Champagne MT. J Nurs Care Qual. 2013;28:139-146.

NEWSPAPER/MAGAZINE ARTICLE

'Alarm fatigue’ a factor in 2nd death.

Kowalczyk L. Boston Globe. September 21, 2011.

NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

ISMP Medication Safety Alert! Acute Care Edition. May 3, 2007;12:1-2.

STUDY

Patient safety, quality care, and service utilization with PLATO (Physician Leadership for Accurate and Timely Orders): a pilot study.

Brunt BA, Gifford IL. J Nurses Staff Dev. 2009;25:E11-E18.

STUDY

Bar code medication administration technology: characterization of high-alert medication triggers and clinician workarounds.

Miller DF, Fortier CR, Garrison KL. Ann Pharmacother. 2011;45:162-168.

NEWSPAPER/MAGAZINE ARTICLE

Scanner beep only means the barcode has been scanned.

ISMP Medication Safety Alert! Acute Care Edition. June 30, 2011;16:1-2.

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