AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (8)

•Diagnostic Errors (1)

•Identification Errors (3)

•Discontinuities, Gaps, and Hand-Off Problems (15)

•Medication Safety (244)

•Medical Complications (4)

•Surgical Complications (1)

•Transfusion Complications (1)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (4)

Resource Types

•Journal Article (140)

•Legislation/Regulation (5)

•Meeting/Conference (4)

•Newspaper/Magazine Article (54)

•Press Release/Announcement (13)

•Tools/Toolkit (12)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (58)

•Active Errors (66)

•Latent Errors (30)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (55)

•Legal and Policy Approaches (19)

•Error Reporting and Analysis (61)

•Communication Improvement (72)

•Human Factors Engineering (98)

•Teamwork (2)

•Specialization of Care (21)

•Logistical Approaches (6)

•Culture of Safety (6)

•Technologic Approaches (60)

•Education and Training (46)

Clinical Areas
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Pharmacy

•Hospital Pharmacy (35)

•Community Pharmacy (11)

Target Audience

•Health Care Providers (194)

•Health Care Executives and Administrators (121)

•Non-Health Care Professionals (45)

•Patients (30)

Setting of Care

•Hospitals (77)

•Residential Facilities (6)

•Ambulatory Care (42)

1 - 20 of 244

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COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2008;43:10-12.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:18-21.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2007;42:396–399.

NEWSPAPER/MAGAZINE ARTICLE

Keeping patients safe from iatrogenic methadone overdoses.

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

NEWSPAPER/MAGAZINE ARTICLE

Neuromuscular blocking agents: reducing associated wrong-drug errors.

PA-PSRS Patient Saf Advis. December 2009;6:109-114.

STUDY

Implementing patient safety practices in small ambulatory care settings.

Schauberger CW, Larson P. Jt Comm J Qual Patient Saf. 2006;32:419-425.

COMMENTARY

International drug name confusion.

Levien TL. Hosp Pharm. 2006;41:697-709.

NEWSPAPER/MAGAZINE ARTICLE

FDA Advise-ERR: medication errors associated with Cerebyx.

ISMP Medication Safety Alert! Acute Care Edition. April 10, 2008;13:1-2.

PRESS RELEASE/ANNOUNCEMENT

Medication errors resulting from confusion between risperidone (Risperdal) and ropinirole (Requip).

MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; June 13, 2011.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:940-945.

MEETING/CONFERENCE PROCEEDINGS

Public Meeting on Improving Patient Safety by Enhancing the Container Labeling for Parenteral Infusion Drug Products.

US Food and Drug Administration, Center for Drug Evaluation and Research. January 11, 2007.

NEWSPAPER/MAGAZINE ARTICLE

Potassium may no longer be stocked on patient care units, but serious threats still exist!

ISMP Medication Safety Alert! Acute Care Edition. October 4, 2007;12:1-2.

NEWSPAPER/MAGAZINE ARTICLE

Catching deadly drug mistakes.

Landro L. Wall Street Journal. January 18, 2010;D5.

AWARD RECIPIENT

Hospitals win safety award for simple changes.

Sipkoff M. Drug Topics (Health-System Edition). January 22, 2007.

STUDY

The influence of 'Tall Man' lettering on errors of visual perception in the recognition of written drug names.

Darker IT, Gerret D, Filik R, Purdy KJ, Gale AG. Ergonomics. 2011;54:21-33.

PRESS RELEASE/ANNOUNCEMENT

Maalox Total Relief and Maalox Liquid Products: Medication Use Errors.

MedWatch Safety Alert. Rockville, MD: US Food and Drug Administration; February 17, 2010.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:288-292.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2007;42:12-13, 36.

PRESS RELEASE/ANNOUNCEMENT

Heparin sodium injection 10,000 units/mL, and HEP-LOCK U/P 10 units/mL medication errors.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 6, 2007.

NEWSPAPER/MAGAZINE ARTICLE

Durasal–Durezol mix-up illustrates how dangerous product problems persist long after recognition.

ISMP Medication Safety Alert! Acute Care Edition. September 22, 2011;16:1-3.

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