AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (19)

•Diagnostic Errors (3)

•Identification Errors (3)

•Discontinuities, Gaps, and Hand-Off Problems (24)

•Medication Safety (317)

•Medical Complications (10)

•Surgical Complications (5)

•Transfusion Complications (1)

Origin/Sponsor

•Australia and New Zealand (9)

•North America (264)

Resource Types

•Audiovisual (6)

•Book/Report (11)

•Journal Article (176)

•Legislation/Regulation (8)

•Meeting/Conference (5)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (66)

•Press Release/Announcement (25)

•Special or Theme Issue (3)

•Tools/Toolkit (15)

•Web Resource (7)

Error Types

•Epidemiology of Errors and Adverse Events (59)

•Active Errors (86)

•Latent Errors (40)

•Near Miss (6)

Approach to Improving Safety

•Quality Improvement Strategies (94)

•Legal and Policy Approaches (29)

•Error Reporting and Analysis (62)

•Communication Improvement (92)

•Human Factors Engineering (110)

•Teamwork (9)

•Specialization of Care (28)

•Logistical Approaches (15)

•Culture of Safety (13)

•Technologic Approaches (88)

•Education and Training (81)

Clinical Areas
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Pharmacy

•Hospital Pharmacy (65)

•Community Pharmacy (15)

Target Audience

•Health Care Providers (289)

•Health Care Executives and Administrators (187)

•Non-Health Care Professionals (70)

•Patients (45)

Setting of Care

•Hospitals (128)

•Psychiatric Facilities (1)

•Residential Facilities (4)

•Ambulatory Care (64)

•Outpatient Surgery (1)

1 - 20 of 327

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PRESS RELEASE/ANNOUNCEMENT

Promethazine HCl (marketed as Phenergan) Information.

FDA Alert [US Food and Drug Administration Web site]. April 25, 2006.

MEETING/CONFERENCE PROCEEDINGS

An Introduction to the Improved FDA Prescription Drug Labeling.

US Food and Drug Administration Center for Drug Evaluation and Research, Institute for Safe Medication Practices. November 7, 2006.

PRESS RELEASE/ANNOUNCEMENT

Kaletra (lopinavir/ritonavir) oral solution.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 13, 2007.

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.

PRESS RELEASE/ANNOUNCEMENT

Important change to heparin container labels to clearly state the total drug strength.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 6, 2012.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

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

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:696–698.

COMMENTARY

Language Barrier

Flores G. AHRQ WebM&M [serial online]. April 2006.

MEETING/CONFERENCE PROCEEDINGS

Developing Guidance on Naming, Labeling, and Packaging Practices to Reduce Medication Errors.

US Food and Drug Administration. June 24–25, 2010; Marriott Residence Inn, Bethesda, MD.

PRESS RELEASE/ANNOUNCEMENT

Important information for the safe use of Tussionex Pennkinetic Extended-Release Suspension.

FDA Public Health Advisory [US Food and Drug Administration Web site]. March 11, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Small patients, big consequences in medical errors.

Tarkan L. New York Times. September 14, 2008;Health section:7.

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.

PRESS RELEASE/ANNOUNCEMENT

Warning! Severe burns and permanent scarring after glacial acetic acid (≥99.5%) mistakenly applied topically.

National Alert Network for Serious Medication Errors. Bethesda, MD: American Society of Health-System Pharmacists and Institute for Safe Medication Practices; January 23, 2013.

STUDY

Systematic evaluation of errors occurring during the preparation of intravenous medication.

Parshuram CS, To T, Seto W, Trope A, Koren G, Laupacis A. CMAJ. 2008;178:42-48.

AUDIOVISUAL

Preventing dosage errors with Diastat AcuDial.

Food and Drug Administration (FDA) Patient Safety News. Show #59. January 2007.

NEWSPAPER/MAGAZINE ARTICLE

Oral syringes: a crucial and economical risk-reduction strategy that has not been fully utilized.

ISMP Medication Safety Alert! Acute Care Edition. October 22, 2009;14:1-3.

COMMENTARY

Medication errors: don't let them happen to you.

Anderson P, Townsend T. Amer Nurs Today. March 2010;5:23-27.

PRESS RELEASE/ANNOUNCEMENT

Vitamin D supplement products: medication use error.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; June 15, 2010.

COMMENTARY

Confusion with Acetaminophen

Heubi JE. AHRQ WebM&M [serial online]. January 2006.

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