AHRQ Patient Safety Network

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Administration Errors

Origin/Sponsor

•Asia (8)

•Australia and New Zealand (10)

•Central and South America (3)

Resource Types

•Clinical Guideline (1)

•Journal Article (220)

•Legislation/Regulation (3)

•Meeting/Conference (1)

•Newspaper/Magazine Article (42)

•Press Release/Announcement (10)

•Special or Theme Issue (3)

•Tools/Toolkit (4)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (87)

•Active Errors (104)

•Latent Errors (26)

•Near Miss (12)

Approach to Improving Safety

•Quality Improvement Strategies (78)

•Legal and Policy Approaches (17)

•Error Reporting and Analysis (78)

•Communication Improvement (32)

•Human Factors Engineering (75)

•Teamwork (4)

•Specialization of Care (15)

•Logistical Approaches (22)

•Culture of Safety (21)

•Technologic Approaches (87)

•Education and Training (67)

Clinical Areas

•Allied Health Services (1)

•Medicine (182)

•Nursing (94)

•Pharmacy (88)

Target Audience

•Health Care Providers (253)

•Health Care Executives and Administrators (239)

•Non-Health Care Professionals (83)

•Patients (24)

Setting of Care

•Hospitals (177)

•Psychiatric Facilities (4)

•Residential Facilities (11)

•Ambulatory Care (18)

•Outpatient Surgery (2)

•Patient Transport (2)

1 - 20 of 296

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COMMENTARY

Preventing vincristine administration errors: does evidence support minibag infusions?

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

NEWSPAPER/MAGAZINE ARTICLE

Nurse is charged in death of patient.

Wahlberg D, Treleven E. Wisconsin State Journal. November 3, 2006:A1.

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.

FACT SHEET/FAQS

Oral Dosage Forms that Should Not Be Crushed.

Mitchell JF. Institute for Safe Medication Practices.

COMMENTARY

Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue].

Syed S, Paul JE, Hueftlein M, Kampf M, McLean RF. Can J Anaesth. 2006;53:586-590.

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.

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.

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.

STUDY

Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error.

Goodman EJ, Haas AJ, Kantor GS. Int J Obstet Anesth. 2006;15:63-67.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing vincristine administration errors.

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

COMMENTARY

Miscalculated Risk

Strassels SA. 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.

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

Not again!

Berwick DM. BMJ. 2001;322:247-248.

NEWSPAPER/MAGAZINE ARTICLE

Fatal drug mix-up exposes hospital flaws.

Davies T. Washington Post. September 22, 2006.

STUDY

A trial of automated decision support alerts for contraindicated medications using computerized physician order entry.

Galanter WL, Didomenico RJ, Polikaitis A. J Am Med Inform Assoc. 2005;12:269-274.

COMMENTARY

Effective strategies to increase reporting of medication errors in hospitals.

Force MV, Deering L, Hubbe J, et al. J Nurs Adm. 2006;36:34-41.

COMMENTARY

Crossed Coverage

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

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