AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (18)

•Identification Errors (3)

•Discontinuities, Gaps, and Hand-Off Problems (32)

•Medication Safety (343)

•Medical Complications (7)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (3)

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•Asia (8)

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•Clinical Guideline (1)

•Journal Article (257)

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•Press Release/Announcement (2)

•Special or Theme Issue (1)

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Error Types

•Epidemiology of Errors and Adverse Events (129)

•Active Errors (76)

•Latent Errors (22)

•Near Miss (5)

Approach to Improving Safety

•Quality Improvement Strategies (55)

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•Error Reporting and Analysis (66)

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•Human Factors Engineering (67)

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•Logistical Approaches (23)

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•Education and Training (43)

Clinical Areas
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Hospital Pharmacy

Target Audience

•Health Care Providers (263)

•Health Care Executives and Administrators (250)

•Non-Health Care Professionals (103)

•Patients (12)

Setting of Care

•Hospitals (328)

•Psychiatric Facilities (1)

•Ambulatory Care (5)

•Outpatient Surgery (2)

1 - 20 of 349

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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

Reevaluating the safety profile of pediatrics: a comparison of computerized adverse drug event surveillance and voluntary reporting in the pediatric environment.

Ferranti J, Horvath MM, Cozart H, Whitehurst J, Eckstrand J. Pediatrics. 2008;121:e1201-e1207.

STUDY

Analysis of overridden alerts in a drug–drug interaction detection system.

Mille F, Schwartz C, Brion F, et al. Int J Qual Health Care. 2008 Dec; 20:400-5.

STUDY

Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals.

Takata GS, Mason W, Taketomo C, Logsdon T, Sharek PJ. Pediatrics. 2008;121:e927-e935.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors occurring with the use of bar-code administration technology.

PA-PSRS Patient Saf Advis. December 2008;5:122-126.

STUDY

Utilising improvement science methods to optimise medication reconciliation.

White CM, Schoettker PJ, Conway PH, et al. BMJ Qual Saf. 2011;20:372-380.

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

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.

REVIEW

Systematic review of medication safety assessment methods.

Meyer-Massetti C, Cheng CM, Schwappach DL, et al. Am J Health Syst Pharm. 2011;68:227-240.

STUDY

Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system.

Longhurst CA, Parast L, Sandborg CI, et al. Pediatrics. 2010;126:14-21.

STUDY

Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients.

Holdsworth MT, Fichtl RE, Raisch DW, et al. Pediatrics. 2007;120:1058-1066.

STUDY

Pharmacists' medication reconciliation-related clinical interventions in a children's hospital.

Gardner B, Graner K. Jt Comm J Qual Patient Saf. 2009;35:278-283.

STUDY

Medication-error alerts for warfarin orders detected by a bar-code-assisted medication administration system.

Fitzhenry F, Doran J, Lobo B, et al. Am J Health Syst Pharm. 2011;68:434-441.

STUDY

Unit-based clinical pharmacists' prevention of serious medication errors in pediatric inpatients.

Kaushal R, Bates DW, Abramson EL, Soukup JR, Goldmann DA. Am J Health Syst Pharm. 2008;65:1254-1260.

STUDY

Reducing medication errors and improving systems reliability using an electronic medication reconciliation system.

Agrawal A, Wu WY. Jt Comm J Qual Patient Saf. 2009;35:106-114.

STUDY

Medication errors resulting from computer entry by nonprescribers.

Santell JP, Kowiatek JG, Weber RJ, Hicks RW, Sirio CA. Am J Health Syst Pharm. 2009;66:843-853.

AUDIOVISUAL

State launches 3rd priority investigation into Children's.

Vedder T. Problem Solvers. KOMO 4 News. October 1, 2010.

NEWSPAPER/MAGAZINE ARTICLE

Supplementary Advisory: Results of the PA-PSRS Workgroup on Pharmacy Computer System Safety.

PA-PSRS Patient Saf Advis. May 2007;4(suppl 2):1-8.

STUDY

Effects of an adverse-drug-event alert system on cost and quality outcomes in community hospitals.

Piontek F, Kohli R, Conlon P, Ellis JJ, Jablonski J, Kini N. Am J Health Syst Pharm. 2010;67:613-620.

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.

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