AHRQ Patient Safety Network

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Administration Errors

Origin/Sponsor

•Asia (10)

•Australia and New Zealand (13)

•Central and South America (3)

Resource Types

•Clinical Guideline (1)

•Journal Article (241)

•Legislation/Regulation (3)

•Meeting/Conference (1)

•Newspaper/Magazine Article (34)

•Press Release/Announcement (9)

•Special or Theme Issue (3)

•Tools/Toolkit (3)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (107)

•Active Errors (118)

•Latent Errors (36)

•Near Miss (12)

Approach to Improving Safety

•Quality Improvement Strategies (85)

•Legal and Policy Approaches (19)

•Error Reporting and Analysis (82)

•Communication Improvement (39)

•Human Factors Engineering (77)

•Teamwork (5)

•Specialization of Care (15)

•Logistical Approaches (25)

•Culture of Safety (21)

•Technologic Approaches (91)

•Education and Training (66)

Clinical Areas

•Allied Health Services (1)

•Medicine (197)

•Nursing (100)

•Pharmacy (88)

Target Audience

•Health Care Providers (263)

•Health Care Executives and Administrators (249)

•Non-Health Care Professionals (89)

•Patients (19)

Setting of Care

•Hospitals (190)

•Psychiatric Facilities (4)

•Residential Facilities (11)

•Ambulatory Care (19)

•Outpatient Surgery (2)

•Patient Transport (3)

1 - 20 of 304

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COMMENTARY

Miscalculated Risk

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

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.

STUDY

Medication prescribing errors involving the route of administration.

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

STUDY

Adverse drug events in hospitalized cardiac patients.

Fanikos J, Cina JL, Baroletti S, Fiumara K, Matta L, Goldhaber SZ. Am J Cardiol. 2007;100:1465-1469.

COMMENTARY

It's All in the Syringe

Weingart SN. AHRQ WebM&M [serial online]. August 2006.

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.

STUDY

Bar-code technology for medication administration: medication errors and nurse satisfaction.

Fowler SB, Sohler P, Zarillo DF. MedSurg Nursing. 2009;18:103-110.

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.

AUDIOVISUAL

Preventing fatal heparin overdoses.

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

STUDY

Effects of technological interventions on the safety of a medication-use system.

Skibinski KA, White BA, Lin LI, Dong Y, Wu W. Am J Health Syst Pharm. 2007;64:90-96.

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

Relationship of incorrect dosing of fibrinolytic therapy and clinical outcomes.

Mehta RH, Alexander JH, Van de Werf F, et al. JAMA. 2005;293:1746-1750.

STUDY

Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.

Colligan L, Guerlain S, Steck SE, Hoke TR. BMJ Qual Saf. 2012;21:939-947.

NEWSPAPER/MAGAZINE ARTICLE

Clear liquids may place patients at risk.

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

COMMENTARY

ISMP medication error report analysis.

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

STUDY

Effect of bar-code–assisted medication administration on medication administration errors and accuracy in multiple patient care areas.

Helmons PJ, Wargel LN, Daniels CE. Am J Health Syst Pharm. 2009;66:1202-1210.

COMMENTARY

Dealing honestly with an honest mistake.

Liang NL, Herring ME, Bush RL. J Vasc Surg. 2010;51:494-495.

STUDY

Adverse drug events caused by serious medication administration errors.

Kale A, Keohane CA, Maviglia S, Gandhi TK, Poon EG. BMJ Qual Saf. 2012;21:933-938.

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