AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (25)

•Diagnostic Errors (3)

•Identification Errors (6)

•Discontinuities, Gaps, and Hand-Off Problems (58)

•Medication Safety (713)

•Medical Complications (12)

•Surgical Complications (5)

•Transfusion Complications (1)

Origin/Sponsor

•Australia and New Zealand (16)

•Central and South America (1)

•North America (605)

Resource Types

•Audiovisual (18)

•Book/Report (17)

•Clinical Guideline (1)

•Journal Article (492)

•Legislation/Regulation (14)

•Meeting/Conference (5)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (128)

•Press Release/Announcement (19)

•Special or Theme Issue (5)

•Tools/Toolkit (20)

•Web Resource (7)

Error Types

•Epidemiology of Errors and Adverse Events (256)

•Active Errors (140)

•Latent Errors (52)

•Near Miss (12)

Approach to Improving Safety

•Quality Improvement Strategies (144)

•Legal and Policy Approaches (50)

•Error Reporting and Analysis (172)

•Communication Improvement (196)

•Human Factors Engineering (128)

•Teamwork (11)

•Specialization of Care (96)

•Logistical Approaches (34)

•Culture of Safety (26)

•Technologic Approaches (249)

•Education and Training (114)

Clinical Areas
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Pharmacy

•Hospital Pharmacy (272)

•Community Pharmacy (72)

Target Audience

•Health Care Providers (606)

•Health Care Executives and Administrators (442)

•Non-Health Care Professionals (188)

•Patients (78)

Setting of Care

•Hospitals (351)

•Psychiatric Facilities (2)

•Residential Facilities (14)

•Ambulatory Care (137)

•Outpatient Surgery (2)

1 - 20 of 732

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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

Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.

Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.

STUDY

Listen carefully: the risk of error in spoken medication orders.

Lambert BL, Dickey LW, Fisher WM, et al. Soc Sci Med. 2010;70:1599-1608.

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

Characteristics of pediatric chemotherapy medication errors in a national error reporting database.

Rinke ML, Shore AD, Morlock L, Hicks RW, Miller MR. Cancer. 2007;110:186-195.

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.

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

Nighttime and weekend medication error rates in an inpatient pediatric population.

Miller AD, Piro CC, Rudisill CN, Bookstaver PB, Bair JD, Bennett CL. Ann Pharmacother. 2010;44:1739-1746.

STUDY

Reducing warfarin medication interactions: an interrupted time series evaluation.

Feldstein AC, Smith DH, Perrin N, et al. Arch Intern Med. 2006;166:1009-1015.

STUDY

Evaluation of inpatient admissions and potential antimicrobial and analgesic dosing errors in overweight children.

Miller JL, Johnson PN, Harrison DL, Hagemann TM. Ann Pharmacother. 2010;44:35-42.

STUDY

Risk factors in preventable adverse drug events in pediatric outpatients.

Zandieh SO, Goldmann DA, Keohane CA, Yoon C, Bates DW, Kaushal R. J Pediatr. 2008;152:225-231.

STUDY

Parenteral nutrition prescribing processes using computerized prescriber order entry: opportunities to improve safety.

Hilmas E, Peoples JD. JPEN J Parenter Enteral Nutr. 2012;36(suppl 2):32S-35S.

STUDY

Risk models to improve safety of dispensing high-alert medications in community pharmacies.

Cohen MR, Smetzer JL, Westphal JE, Comden SC, Horn DM. J Am Pharm Assoc. 2012;52:584-602.

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.

NEWSPAPER/MAGAZINE ARTICLE

Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives.

ISMP Medication Safety Alert! Acute Care Edition. February 9, 2012;17:1-4.

BOOK/REPORT classic

classic

Preventing Medication Errors: Quality Chasm Series.

Committee on Identifying and Preventing Medication Errors, Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007.

STUDY

Effectiveness of a pharmacist–nurse intervention on resolving medication discrepancies for patients transitioning from hospital to home health care.

Setter SM, Corbett CF, Neumiller JJ, Gates BJ, Sclar DA, Sonnett TE. Am J Health Syst Pharm. 2009;66:2027-2031.

STUDY

Predictive value of alert triggers for identification of developing adverse drug events.

Moore C, Li J, Hung CC, Downs J, Nebeker JR. J Patient Saf. 2009;5:223-228.

STUDY

Hospital admission medication reconciliation in medically complex children: an observational study.

Stone BL, Boehme S, Mundorff MB, Maloney CG, Srivastava R. Arch Dis Child. 2010;95:250-255.

NEWSPAPER/MAGAZINE ARTICLE

Medication administration in anesthesia: time for a paradigm shift.

Stabile M, Webster CS, Merry AF. APSF Newsletter. Fall 2007;22:44-47.

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