AHRQ Patient Safety Network

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Anticoagulants

Origin/Sponsor

•Australia and New Zealand (2)

•Central and South America (1)

•North America (68)

Resource Types

•Audiovisual (2)

•Book/Report (1)

•Clinical Guideline (1)

•Journal Article (51)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (18)

•Press Release/Announcement (4)

•Tools/Toolkit (1)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (24)

•Active Errors (23)

•Latent Errors (8)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (22)

•Legal and Policy Approaches (7)

•Error Reporting and Analysis (27)

•Communication Improvement (17)

•Human Factors Engineering (22)

•Teamwork (1)

•Specialization of Care (17)

•Logistical Approaches (6)

•Technologic Approaches (29)

•Education and Training (11)

Clinical Areas

•Medicine (66)

•Pharmacy (34)

Target Audience

•Health Care Providers (63)

•Health Care Executives and Administrators (54)

•Non-Health Care Professionals (11)

•Patients (11)

Setting of Care

•Hospitals (59)

•Residential Facilities (5)

•Ambulatory Care (7)

•Outpatient Surgery (1)

1 - 20 of 82

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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.

STUDY

Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance.

Classen DC, Jaser L, Budnitz DS. Jt Comm J Qual Patient Saf. 2010;36:12-21, AP1-AP9.

STUDY

Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality improvement opportunities.

Hansen RA, Cornell PY, Ryan PB, Williams CE, Pierson S, Greene SB. Pharmacoepidemiol Drug Saf. 2010;19:1087-1094.

NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

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

NEWSPAPER/MAGAZINE ARTICLE

Common cause analysis.

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

BOOK/REPORT

Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety.

Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.

STUDY

The safety of warfarin therapy in the nursing home setting.

Gurwitz JH, Field TS, Radford MJ, et al. Am J Med. 2007;120:539-544.

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

Dementia and risk of adverse warfarin-related events in the nursing home setting.

Tjia J, Field TS, Mazor KM, et al. Am J Geriatr Pharmacother. 2012;10:323-330.

NEWSPAPER/MAGAZINE ARTICLE

Collaboration focused on priority issues promotes safety.

ISMP Medication Safety Alert! Acute Care Edition. October 10, 2008;13:1-3.

STUDY

classic

Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System.

Metersky ML, Hunt DR, Kliman R, et al. Med Care. 2011;49:504-510.

COMMENTARY

Dealing honestly with an honest mistake.

Liang NL, Herring ME, Bush RL. J Vasc Surg. 2010;51:494-495.

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.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety records: silent witness.

Gould M. Health Service Journal. September 15, 2008:22-24.

STUDY

Emergency department visits for outpatient adverse drug events: demonstration for a national surveillance system.

Budnitz DS, Pollock DA, Mendelsohn AB, Weidenbach KN, McDonald AK, Annest JL. Ann Emerg Med. 2005;45:197-206.

NEWSPAPER/MAGAZINE ARTICLE

Heparin: improving treatment and reducing risk of harm.

Daner WE, Gosselin RC, Raschke R, Vanderveen T. Patient Saf Qual Healthcare. January/February 2009;6:20-25.

STUDY

classic

Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial.

Strom BL, Schinnar R, Aberra F, et al. Arch Intern Med. 2010;170:1578-1583.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

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

STUDY

Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.

Grissinger MC, Hicks RW, Keroack MA, Marella WM, Vaida A. Jt Comm J Qual Patient Saf. 2010;36:195-202.

STUDY

Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention.

Tsai TT, Maddox TM, Roe MT, et al; National Cardiovascular Data Registry. JAMA. 2009;302:2458-2464.

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