AHRQ Patient Safety Network

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Administration Errors

Origin/Sponsor

•Africa (1)

•Asia (12)

•Australia and New Zealand (14)

•Central and South America (4)

Resource Types

•Journal Article (258)

•Legislation/Regulation (5)

•Meeting/Conference (1)

•Newspaper/Magazine Article (42)

•Press Release/Announcement (11)

•Special or Theme Issue (5)

•Tools/Toolkit (3)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (103)

•Active Errors (136)

•Latent Errors (36)

•Near Miss (12)

Approach to Improving Safety

•Quality Improvement Strategies (83)

•Legal and Policy Approaches (20)

•Error Reporting and Analysis (86)

•Communication Improvement (41)

•Human Factors Engineering (96)

•Teamwork (5)

•Specialization of Care (15)

•Logistical Approaches (25)

•Culture of Safety (21)

•Technologic Approaches (99)

•Education and Training (72)

Clinical Areas

•Medicine (208)

•Nursing (100)

•Pharmacy (97)

Target Audience

•Health Care Providers (284)

•Health Care Executives and Administrators (266)

•Non-Health Care Professionals (105)

•Patients (26)

Setting of Care

•Hospitals (207)

•Psychiatric Facilities (4)

•Residential Facilities (9)

•Ambulatory Care (22)

•Outpatient Surgery (2)

•Patient Transport (3)

1 - 20 of 336

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STUDY

Nurses' behaviors and visual scanning patterns may reduce patient identification errors.

Marquard JL, Henneman PL, He Z, Jo J, Fisher DL, Henneman EA. J Exp Psychol Appl. 2011;17:247-256.

STUDY

Drug formulations that require potentially inaccurate volumes to prepare doses for infants and children.

Uppal N, Yasseen B, Seto W, Parshuram CS. CMAJ. 2011;183:E246-E248.

PRESS RELEASE/ANNOUNCEMENT

Serious medication errors from intravenous administration of nimodipine oral capsules.

MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; August 2, 2010.

STUDY

Frequency and type of errors and near errors reported by critical care nurses.

Balas MC, Scott LD, Rogers AE. Can J Nurs Res. 2006;38:24-41.

STUDY

Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration.

Yamamoto L, Kanemori J. Am J Emerg Med. 2010;28:588-592.

COMMENTARY

Time to get off this pig's back?: the human factors aspects of the mismatch between device and real-world knowledge in the health care environment.

Nunnally ME, Bitan Y. J Patient Saf. 2006;2:124-131.

STUDY

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit.

Stavroudis TA, Shore AD, Morlock L, Hicks RW, Bundy D, Miller MR. J Perinatol. 2010;30:459-468.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:282-287.

NEWSPAPER/MAGAZINE ARTICLE

Fatal outcome after inadvertent injection of topical epinephrine.

ISMP Medication Safety Alert! Acute Care Edition. March 26, 2009;14:1-2.

STUDY

Medication safety initiative in reducing medication errors.

Nguyen EE, Connolly PM, Wong V. J Nurs Care Qual. 2010;25:224-230.

STUDY

Variability in the concentrations of intravenous drug infusions prepared in a critical care unit.

Wheeler DW, Degnan BA, Sehmi JS, et al. Intensive Care Med. 2008;34:1441-1447.

COMMENTARY

ISMP medication error report analysis.

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

STUDY

Medication Administration Time Study (MATS): nursing staff performance of medication administration.

Elganzouri ES, Standish CA, Androwich I. J Nurs Adm. 2009;39:204-210.

STUDY

Nurses' clinical reasoning: processes and practices of medication safety.

Dickson GL, Flynn L. Qual Health Res. 2012;22:3-16.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010:45;352-355.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:288-292.

COMMENTARY

Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution.

Kanwar M, Irvin CB, Frank JJ, Weber K, Rosman H. Ann Emerg Med. 2010;55:341-344.

STUDY

Nurse interruptions pre- and post-implementation of a point-of-care medication administration system.

Stamp KD, Willis DG. J Nurs Care Qual. 2010;25:231-239.

STUDY

Risk and pharmacoeconomic analyses of the injectable medication process in the paediatric and neonatal intensive care units.

De Giorgi I, Fonzo-Christe C, Cingria L, et al. Int J Qual Health Care. 2010;22:170-178.

NEWSPAPER/MAGAZINE ARTICLE

Medication administration in anesthesia: time for a paradigm shift.

Stabile M, Webster CS, Merry AF. APSF Newsletter. Fall 2007;22:44-47.

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