AHRQ Patient Safety Network

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Administration Errors

Origin/Sponsor

•Africa (1)

•Asia (10)

•Australia and New Zealand (14)

•Central and South America (4)

Resource Types

•Journal Article (251)

•Legislation/Regulation (5)

•Meeting/Conference (1)

•Newspaper/Magazine Article (43)

•Press Release/Announcement (10)

•Special or Theme Issue (5)

•Tools/Toolkit (4)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (102)

•Active Errors (135)

•Latent Errors (37)

•Near Miss (11)

Approach to Improving Safety

•Quality Improvement Strategies (83)

•Legal and Policy Approaches (20)

•Error Reporting and Analysis (81)

•Communication Improvement (41)

•Human Factors Engineering (96)

•Teamwork (5)

•Specialization of Care (14)

•Logistical Approaches (26)

•Culture of Safety (22)

•Technologic Approaches (95)

•Education and Training (72)

Clinical Areas

•Allied Health Services (1)

•Medicine (210)

•Nursing (100)

•Pharmacy (96)

Target Audience

•Health Care Providers (278)

•Health Care Executives and Administrators (263)

•Non-Health Care Professionals (102)

•Patients (26)

Setting of Care

•Hospitals (201)

•Psychiatric Facilities (3)

•Residential Facilities (10)

•Ambulatory Care (20)

•Outpatient Surgery (2)

•Patient Transport (3)

1 - 20 of 330

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STUDY

Evaluation of inpatient admissions and potential antimicrobial and analgesic dosing errors in overweight children.

Miller JL, Johnson PN, Harrison DL, Hagemann TM. Ann Pharmacother. 2010;44:35-42.

COMMENTARY

Caution, Interrupted.

Wears RL. AHRQ WebM&M [serial online]. September 2004.

STUDY

Nursing care quality and adverse events in US hospitals.

Lucero RJ, Lake ET, Aiken LH. J Clin Nurs. 2010;19:2185-2195.

STUDY

Effect of bar-code technology on the safety of medication administration.

Poon EG, Keohane CA, Yoon CS, et al. N Engl J Med. 2010;362:1698-1707.

COMMENTARY

Addressing safety concerns about U-500 insulin in a hospital setting.

Samaan KH, Dahlke M, Stover J. Am J Health Syst Pharm. 2011;68:63-68.

NEWSPAPER/MAGAZINE ARTICLE

Administering a saline flush "site unseen" can lead to a wrong route error.

ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.

STUDY

Medication safety initiative in reducing medication errors.

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

NEWSPAPER/MAGAZINE ARTICLE

Guidelines for timely medication administration: response to the CMS "30-minute rule."

ISMP Medication Safety Alert! Acute Care Edition. January 13, 2011;16:1-4.

NEWSPAPER/MAGAZINE ARTICLE

Oral syringes: a crucial and economical risk-reduction strategy that has not been fully utilized.

ISMP Medication Safety Alert! Acute Care Edition. October 22, 2009;14:1-3.

COMMENTARY classic

Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.

STUDY

Self-reported violations during medication administration in two paediatric hospitals.

Alper SJ, Holden RJ, Scanlon MC, et al. BMJ Qual Saf. 2012;21:408-415.

COMMENTARY

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43;788-792.

STUDY

Prevention of pediatric medication errors by hospital pharmacists and the potential benefit of computerized physician order entry.

Wang JK, Herzog NS, Kaushal R, et al. Pediatrics. 2007;119:e77-85.

BOOK/REPORT

Fluorouracil Incident Root Cause Analysis Report.

Toronto, ON, Canada: Institute for Safe Medication Practices Canada. May 8, 2007.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:937-938, 945.

STUDY

Interruption handling strategies during paediatric medication administration.

Colligan L, Bass EJ. BMJ Qual Saf. 2012;21:912-917.

NEWSPAPER/MAGAZINE ARTICLE

Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.

ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.

COMMENTARY

ISMP medication error report analysis.

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

COMMENTARY

Implementing a safe and reliable process for medication administration.

Richardson B, Bromirski B, Hayden A. Clin Nurse Spec. 2012;26:169-176.

STUDY

A secondary care nursing perspective on medication administration safety.

McBride-Henry K, Foureur M. J Adv Nurs. 2007;60:58-66.

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