AHRQ Patient Safety Network

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Specific to High-Risk Drugs

•Anticoagulants (72)

•Insulin (38)

•Chemotherapeutic Agents (59)

•Look-Alike, Sound-Alike Drugs (72)

•Opiates/Narcotics (48)

Origin/Sponsor

•Australia and New Zealand (7)

•Central and South America (2)

•North America (294)

Resource Types

•Audiovisual (5)

•Book/Report (7)

•Clinical Guideline (2)

•Journal Article (235)

•Legislation/Regulation (6)

•Meeting/Conference (1)

•Newspaper/Magazine Article (70)

•Press Release/Announcement (13)

•Special or Theme Issue (1)

•Tools/Toolkit (9)

•Web Resource (6)

Error Types

•Epidemiology of Errors and Adverse Events (100)

•Active Errors (131)

•Latent Errors (35)

•Near Miss (11)

Approach to Improving Safety

•Quality Improvement Strategies (117)

•Legal and Policy Approaches (25)

•Error Reporting and Analysis (103)

•Communication Improvement (78)

•Human Factors Engineering (99)

•Teamwork (8)

•Specialization of Care (32)

•Logistical Approaches (13)

•Culture of Safety (13)

•Technologic Approaches (96)

•Education and Training (72)

Clinical Areas

•Allied Health Services (1)

•Medicine (241)

•Nursing (29)

•Pharmacy (148)

Target Audience

•Health Care Providers (298)

•Health Care Executives and Administrators (247)

•Non-Health Care Professionals (58)

•Patients (35)

Setting of Care

•Hospitals (203)

•Psychiatric Facilities (1)

•Residential Facilities (10)

•Ambulatory Care (61)

•Outpatient Surgery (3)

1 - 20 of 357

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STUDY

Prescribing discrepancies likely to cause adverse drug events after patient transfer.

Boockvar KS, Liu S, Goldstein N, Nebeker J, Siu A, Fried T. Qual Saf Health Care. 2009;18:32-36.

REVIEW

Year in review: medication mishaps in the elderly.

Peron EP, Marcum ZA, Boyce R, Hanlon JT, Handler SM. Am J Geriatr Pharmacother. 2011;9:1-10.

STUDY

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.

COMMENTARY

Opioids, iatrogenic harm and disclosure of medical error.

Blinderman CD. J Pain Symptom Manage. 2010;39:309-313.

NEWSPAPER/MAGAZINE ARTICLE

USP initiatives for the safe use of medical gases.

Zaidi K, Curry PD Jr, Becker SC. Pharmaceutical Technology. November 2, 2005;29:102-103.

STUDY

Cardiovascular medication errors in children.

Alexander DC, Bundy DG, Shore AD, Morlock L, Hicks RW, Miller MR. Pediatrics. 2009;124:324-332.

CLINICAL GUIDELINE classic

classic

Medication errors in acute cardiovascular and stroke patients. A scientific statement from the American Heart Association.

Michaels AD, Spinler SA, Leeper B, et al; American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology, Council on Quality of Care and Outcomes Research, Council on Cardiopulmonary, Critical Care, Perioperative, and Resuscitation, Council on Cardiovascular Nursing, Stroke Council. Circulation. 2010;121:1664-1682.

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

Your high-alert medication list—relatively useless without associated risk-reduction strategies.

ISMP Medication Safety Alert! Acute Care Edition. April 4, 2013;18:1-5.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:847-853.

NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

ISMP Medication Safety Alert! Acute Care Edition. May 3, 2007;12:1-2.

STUDY

Listen carefully: the risk of error in spoken medication orders.

Lambert BL, Dickey LW, Fisher WM, et al. Soc Sci Med. 2010;70:1599-1608.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:1062-1065.

STUDY

Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach.

Field TS, Tjia J, Mazor KM, et al. Am J Med. 2011;124:179.e1-179.e7.

COMMENTARY

Eptifibatide Epilogue

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

NEWSPAPER/MAGAZINE ARTICLE

Common cause analysis.

Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.

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

Adverse drug events resulting from patient errors in older adults.

Field TS, Mazor KM, Briesacher B, Debellis KR, Gurwitz JH. J Am Geriatr Soc. 2007;55:271-276.

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.

STUDY

Preventing medication errors in long-term care: results and evaluation of a large scale web-based error reporting system.

Pierson S, Hansen R, Greene S, Williams C, Akers R, Jonsson M, Carey T. Qual Saf Health Care. 2007;16:297-302.

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