AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (18)

•Identification Errors (3)

•Discontinuities, Gaps, and Hand-Off Problems (34)

•Medication Safety (340)

•Medical Complications (8)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (4)

Origin/Sponsor

•Australia and New Zealand (11)

•Central and South America (2)

•North America (288)

Resource Types

•Audiovisual (5)

•Book/Report (8)

•Clinical Guideline (1)

•Journal Article (250)

•Legislation/Regulation (9)

•Newspaper/Magazine Article (63)

•Press Release/Announcement (2)

•Special or Theme Issue (1)

•Tools/Toolkit (5)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (119)

•Active Errors (72)

•Latent Errors (24)

•Near Miss (6)

Approach to Improving Safety

•Quality Improvement Strategies (57)

•Legal and Policy Approaches (18)

•Error Reporting and Analysis (64)

•Communication Improvement (85)

•Human Factors Engineering (67)

•Teamwork (3)

•Specialization of Care (84)

•Logistical Approaches (24)

•Culture of Safety (15)

•Technologic Approaches (171)

•Education and Training (44)

Clinical Areas
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Hospital Pharmacy

Target Audience

•Health Care Providers (266)

•Health Care Executives and Administrators (246)

•Non-Health Care Professionals (95)

•Patients (12)

Setting of Care

•Hospitals (327)

•Psychiatric Facilities (1)

•Ambulatory Care (6)

•Outpatient Surgery (2)

1 - 20 of 347

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REVIEW

classic

Hospital-based medication reconciliation practices: a systematic review.

Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Arch Intern Med. 2012;172:1057-1069.

NEWSPAPER/MAGAZINE ARTICLE

Enhanced medication safety.

Mansur JM. Hosp Health Netw. April 29, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Medication reconciliation only as good as the IT allows.

Page D. Hosp Health Networks. March 2011.

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.

COMMENTARY

Implementation of a specialized pharmacy team to monitor high-risk medications during discharge.

Martin ES III, Overstreet RL, Jackson-Khalil LR, McCollough HL, Meyer TA, Xu Q. Am J Health Syst Pharm. 2013;70:18-21.

COMMENTARY

Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge.

Murphy EM, Oxencis CJ, Klauck JA, Meyer DA, Zimmerman JM. Am J Health Syst Pharm. 2009;66:2126-2131.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2007;42:884–888.

STUDY

Reporting trends in a regional medication error data-sharing system.

Anderson JG, Ramanujam R, Hensel DJ, Sirio CA. Health Care Manag Sci. 2010;13:74-83.

STUDY

Effect of patient- and medication-related factors on inpatient medication reconciliation errors.

Salanitro AH, Osborn CY, Schnipper JL, et al. J Gen Intern Med. 2012;27:924-932.

STUDY

Impact of a pharmacist on medication reconciliation on patient admission to a Veterans Affairs Medical Center.

Strunk LB, Matson AW, Steinke D. Hosp Pharm. 2008;43:643-649.

NEWSPAPER/MAGAZINE ARTICLE

A shortage of everything except errors: harm associated with drug shortages.

ISMP Medication Safety Alert! Acute Care Edition. April 19, 2012;17:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Anticoagulant safety practices call for pharmacist supervision.

Scott A. Drug Topics (Health-System Edition). November 10, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Misprogramming PCA concentration leads to dosing errors.

ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Answers to improved medication reconciliation lie with pharmacists.

Barbella M. Drug Topics (Digital Edition). November 19, 2007.

STUDY

Impact of a pharmacotherapy alerting system on medication errors.

Natali BJ, Varkey AC, Garey KW, Liebl M. Am J Health Syst Pharm. 2013;70:48-52.

STUDY

classic

Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial.

Kripalani S, Roumie CL, Dalal AK, et al; PILL-CVD (Pharmacist Intervention for Low Literacy in Cardiovascular Disease) Study Group. Ann Intern Med. 2012;157:1-10.

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.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

STUDY

Rural inpatient telepharmacy consultation demonstration for after-hours medication review.

Cole SL, Grubbs JH, Din C, Nesbitt TS. Telemed E Health. 2012;18:530-537.

STUDY

Improving medication safety with accurate preadmission medication lists and postdischarge education.

Gardella JE, Cardwell TB, Nnadi M. Jt Comm J Qual Patient Saf. 2012;38:452-458.

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