AHRQ Patient Safety Network

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Administration Errors

Origin/Sponsor

•Asia (8)

•Australia and New Zealand (12)

•Central and South America (2)

Resource Types

•Clinical Guideline (1)

•Journal Article (204)

•Legislation/Regulation (3)

•Meeting/Conference (1)

•Newspaper/Magazine Article (30)

•Press Release/Announcement (11)

•Special or Theme Issue (4)

•Tools/Toolkit (2)

Error Types

•Epidemiology of Errors and Adverse Events (74)

•Active Errors (101)

•Latent Errors (36)

•Near Miss (10)

Approach to Improving Safety

•Quality Improvement Strategies (80)

•Legal and Policy Approaches (13)

•Error Reporting and Analysis (66)

•Communication Improvement (37)

•Human Factors Engineering (68)

•Teamwork (3)

•Specialization of Care (14)

•Logistical Approaches (23)

•Culture of Safety (19)

•Technologic Approaches (73)

•Education and Training (58)

Clinical Areas

•Allied Health Services (1)

•Medicine (161)

•Nursing (89)

•Pharmacy (70)

Target Audience

•Health Care Providers (239)

•Health Care Executives and Administrators (216)

•Non-Health Care Professionals (73)

•Patients (15)

Setting of Care

•Hospitals (155)

•Psychiatric Facilities (3)

•Residential Facilities (7)

•Ambulatory Care (20)

•Outpatient Surgery (1)

•Patient Transport (1)

1 - 20 of 263

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NEWSPAPER/MAGAZINE ARTICLE

Promethazine conundrum: IV can hurt more than IM injection!

ISMP Medication Safety Alert! Acute Care Edition. November 2, 2006;11:1-3.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:725-728.

COMMENTARY

Crossed Coverage

Kayser SR. AHRQ WebM&M [serial online]. February 2007.

NEWSPAPER/MAGAZINE ARTICLE

Tablet splitting: Do it only if you "half" to, and then do it safely.

ISMP Medication Safety Alert! Acute Care Edition. May 18, 2006;11:1-2.

COMMENTARY

Getting to the Root of the Matter

Flanders SA, Saint S. AHRQ WebM&M [serial online]. June 2005.

COMMENTARY

Miscalculated Risk

Strassels SA. AHRQ WebM&M [serial online]. August 2006.

COMMENTARY

A Troubling Amine

Flynn EA. AHRQ WebM&M [serial online]. September 2006.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing vincristine administration errors.

The Joint Commission. Sentinel Event Alert. July 14, 2005;(34):1-3.

STUDY

Medication errors in intravenous drug preparation and administration: a multicentre audit in the UK, Germany and France.

Cousins DH, Sabatier B, Begue D, Schmitt C, Hoppe-Tichy T. Qual Saf Health Care. 2005;14:190-195.

FACT SHEET/FAQS

Oral Dosage Forms that Should Not Be Crushed.

Mitchell JF. Institute for Safe Medication Practices.

AUDIOVISUAL

Preventing fatal heparin overdoses.

Food and Drug Administration (FDA) Patient Safety News. Show #58. December 2006.

PRESS RELEASE/ANNOUNCEMENT

Mix-up (wrong route of administration) of bladder irrigation with intravenous (IV) infusions.

VA National Center for Patient Safety. Washington, DC: VA Central Office; April 6, 2006. Patient Safety Alert AL06-012.

NEWSPAPER/MAGAZINE ARTICLE

IV potassium given epidurally: getting to the "route" of the problem.

ISMP Medication Safety Alert! Acute Care Edition. April 6, 2006;11:1-2.

COMMENTARY

Language Barrier

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

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:556-557.

STUDY

Infant deaths associated with cough and cold medications—two states, 2005.

Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2007;56:1-4.

STUDY

Medication prescribing errors involving the route of administration.

Lesar TS. Hosp Pharm. 2006;41:1053-1066.

NEWSPAPER/MAGAZINE ARTICLE

Clear liquids may place patients at risk.

PA-PSRS Patient Saf Advis. December 2005;2:29-31.

COMMENTARY

Preventing vincristine administration errors: does evidence support minibag infusions?

Schulmeister L. Clin J Oncol Nurs. 2006;10:271-273.

STUDY

Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes.

Alexander KP, Chen AY, Roe MT, et al; CRUSADE Investigators. JAMA. 2005;294:3108-3116.

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