AHRQ Patient Safety Network

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Specific to High-Risk Drugs

•Anticoagulants (30)

•Insulin (19)

•Chemotherapeutic Agents (27)

•Look-Alike, Sound-Alike Drugs (32)

•Opiates/Narcotics (24)

Origin/Sponsor

•Africa (2)

•Asia (4)

•Australia and New Zealand (3)

•Central and South America (2)

Resource Types

•Clinical Guideline (1)

•Journal Article (120)

•Legislation/Regulation (3)

•Meeting/Conference (1)

•Newspaper/Magazine Article (38)

•Press Release/Announcement (12)

•Special or Theme Issue (1)

•Tools/Toolkit (3)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (40)

•Active Errors (78)

•Latent Errors (19)

•Near Miss (9)

Approach to Improving Safety

•Quality Improvement Strategies (61)

•Legal and Policy Approaches (8)

•Error Reporting and Analysis (49)

•Communication Improvement (38)

•Human Factors Engineering (77)

•Teamwork (4)

•Specialization of Care (20)

•Logistical Approaches (9)

•Culture of Safety (6)

•Technologic Approaches (54)

•Education and Training (37)

Clinical Areas

•Medicine (129)

•Nursing (17)

•Pharmacy (95)

Target Audience

•Health Care Providers (168)

•Health Care Executives and Administrators (139)

•Non-Health Care Professionals (29)

•Patients (16)

Setting of Care

•Hospitals (116)

•Psychiatric Facilities (1)

•Residential Facilities (4)

•Ambulatory Care (24)

•Outpatient Surgery (1)

1 - 20 of 187

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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.

STUDY

Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II.

Garrouste-Orgeas M, Timsit JF, Vesin A, et al; OUTCOMEREA Study Group. Am J Respir Crit Care Med. 2010:181:134-142.

STUDY

Thomas AN, Panchagnula U. Anaesthesia. 2008;63:726-733.

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.

STUDY

Drug dosing error with drops – severe clinical course of codeine intoxication in twins.

Hermanns-Clausen M, Weinmann W, Auwärter V, et al. Eur J Pediatr. 2009;168:819-824.

STUDY

A multifaceted program for improving quality of care in intensive care units: IATROREF study.

Garrouste-Orgeas M, Soufir L, Tabah A, et al; Outcomerea Study Group. Crit Care Med. 2012;40:468-476.

COMMENTARY

ISMP medication error report analysis.

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

COMMENTARY

ISMP medication error report analysis.

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

BOOK/REPORT

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.

Toft B. London, England: Department of Health; 2001.

BOOK/REPORT

Vincristine: Learning from Error Workshop.

World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2008.

NEWSPAPER/MAGAZINE ARTICLE

Sterile water should not be given "freely."

PA-PSRS Patient Saf Advis. June 2008;5:53-56.

ORGANIZATIONAL POLICY/GUIDELINES

Vincristine (and other vinca alkaloids) should only be given intravenously via a minibag.

Information Exchange System Alert. Geneva, Switzerland: World Health Organization; July 18, 2007.

BOOK/REPORT

Fluorouracil Incident Root Cause Analysis Report.

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

STUDY

A comparison of voluntarily reported medication errors in intensive care and general care units.

Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.

NEWSPAPER/MAGAZINE ARTICLE

Drug package inserts get mixed reception.

Mitka M. JAMA. 2006;295:1110-1111.

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.

REVIEW

The safety of intravenous drug delivery systems: update on current issues since the 1999 Consensus Development Conference.

Sanborn M, Gabay M, Moody ML. Hosp Pharm. 2009;44:159-164.

COMMENTARY

The quest to eliminate intrathecal vincristine errors: a 40-year journey.

Noble DJ, Donaldson LJ. Qual Saf Health Care. 2010;19:323-326.

COMMENTARY

ISMP medication error report analysis.

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

PRESS RELEASE/ANNOUNCEMENT

Morphine sulfate oral solution 100 mg per 5 mL (20 mg/mL): medication use error—reports of accidental overdose.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 10, 2011.

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