AHRQ Patient Safety Network

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Specific to High-Risk Drugs

•Anticoagulants (65)

•Insulin (36)

•Chemotherapeutic Agents (54)

•Look-Alike, Sound-Alike Drugs (70)

•Opiates/Narcotics (48)

Origin/Sponsor

•Africa (2)

•Asia (4)

•Australia and New Zealand (7)

•Central and South America (2)

Resource Types

•Clinical Guideline (2)

•Journal Article (227)

•Legislation/Regulation (5)

•Meeting/Conference (1)

•Newspaper/Magazine Article (70)

•Press Release/Announcement (7)

•Special or Theme Issue (1)

•Tools/Toolkit (9)

•Web Resource (5)

Error Types

•Epidemiology of Errors and Adverse Events (92)

•Active Errors (115)

•Latent Errors (34)

•Near Miss (10)

Approach to Improving Safety

•Quality Improvement Strategies (109)

•Legal and Policy Approaches (25)

•Error Reporting and Analysis (102)

•Communication Improvement (69)

•Human Factors Engineering (90)

•Teamwork (8)

•Specialization of Care (33)

•Logistical Approaches (13)

•Culture of Safety (16)

•Technologic Approaches (103)

•Education and Training (67)

Clinical Areas

•Allied Health Services (1)

Target Audience

•Health Care Providers (285)

•Health Care Executives and Administrators (233)

•Non-Health Care Professionals (58)

•Patients (30)

Setting of Care

•Hospitals (201)

•Psychiatric Facilities (1)

•Residential Facilities (10)

•Ambulatory Care (54)

•Outpatient Surgery (3)

1 - 20 of 341

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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.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

NEWSPAPER/MAGAZINE ARTICLE

CPOE: it don't come easy.

Anderson HJ. Health Data Manag. January 1, 2009;17:18.

COMMENTARY

The Role of Bar Coding and Smart Pumps in Safety

Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN AHRQ WebM&M [serial online]. September 2008.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

STUDY

A case study on the safety impact of implementing smart patient-controlled analgesic pumps at a tertiary care academic medical center.

Tran M, Ciarkowski S, Wagner D, Stevenson JG. Jt Comm J Qual Patient Saf. 2012;38:112-119.

NEWSPAPER/MAGAZINE ARTICLE

Anticoagulant safety practices call for pharmacist supervision.

Scott A. Drug Topics (Health-System Edition). November 10, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Misprogramming PCA concentration leads to dosing errors.

ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.

STUDY

Factors associated with reported preventable adverse drug events: a retrospective, case-control study.

Beckett RD, Sheehan AH, Reddan JG. Ann Pharmacother. 2012;46:634-641.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

STUDY

An exploratory study measuring verbal order content and context.

Wakefield DS, Brokel J, Ward MM, Schwichtenberg T, Groath D, Kolb M, Davis JW, Crandall D. Qual Saf Health Care. 2009;18:169-173.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:960-964.

COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

AUDIOVISUAL PRESENTATION

When things go wrong.

Institute for Healthcare Improvement. Campaign Live. August 18, 2008.

COMMENTARY

Eptifibatide Epilogue

Churchill WW, Fiumara K. AHRQ WebM&M [serial online]. April 2009.

STUDY

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.

COMMENTARY classic

Computerization can create safety hazards: a bar-coding near miss.

McDonald CJ. Ann Intern Med. 2006;144:510-516.

STUDY

A multifaceted approach to safety: the synergistic detection of adverse drug events in adult inpatients.

Ferranti J, Horvath MM, Cozart H, et al. J Patient Saf. 2008;4:184-190.

COMMENTARY

Anticoagulation patient safety goal compliance at a university health system: methods for achieving the goal.

Franco AC, Maxwell P, Green K, Barthol C. Hosp Pharm. 2009;44:776-780, 784.

STUDY

Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy.

Waitman LR, Phillips IE, McCoy AB, et al. Jt Comm J Qual Patient Saf. 2011;37:326-332.

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