AHRQ Patient Safety Network

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Monitoring Errors and Failures

Origin/Sponsor

•Europe (1)

•North America (13)

Resource Types

•Journal Article (16)

•Newspaper/Magazine Article (2)

Error Types

•Epidemiology of Errors and Adverse Events (3)

•Active Errors (6)

•Latent Errors (1)

Approach to Improving Safety

•Quality Improvement Strategies (4)

•Error Reporting and Analysis (3)

•Communication Improvement (4)

•Human Factors Engineering (2)

•Teamwork (1)

•Logistical Approaches (2)

•Technologic Approaches (11)

•Education and Training (5)

Clinical Areas

•Medicine (14)

•Nursing (2)

•Pharmacy (2)

Target Audience

•Health Care Providers (16)

•Health Care Executives and Administrators (12)

•Non-Health Care Professionals (5)

•Patients (2)

Setting of Care

•Hospitals (9)

•Residential Facilities (2)

•Ambulatory Care (5)

1 - 18 of 18

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STUDY

Assessing and monitoring override medications in automated dispensing devices.

Kowiatek JG, Weber RJ, Skledar SJ, Frank S, DeVita M. Jt Comm J Qual Patient Saf. 2006;32:309-317.

STUDY

Evaluation of laboratory monitoring alerts within a computerized physician order entry system for medication orders.

Palen TE, Raebel M, Lyons E, Magid DM. Am J Manag Care. 2006;12:389-395.

COMMENTARY

Bleeding Risk.

Crowther MA. AHRQ WebM&M [serial online]. July 2003.

STUDY

Nonfatal, unintentional medication exposures among young children—United States, 2001–2003.

Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. January 13, 2006;55:1-5.

NEWSPAPER/MAGAZINE ARTICLE

200 epidural blunders admitted after three women die.

Oakeshott I. The Sunday Times. June 18, 2006.

STUDY

The importance of establishing regimen concordance in preventing medication errors in anticoagulant care.

Schillinger D, Wang F, Rodriguez M, Bindman A, Machtinger EL. J Health Comm. 2006;11:555-567.

COMMENTARY

One ACE Too Many

Juurlink DN. AHRQ WebM&M [serial online]. July 2006.

COMMENTARY

System errors in intrapartum electronic fetal monitoring: a case review.

Miller LA. J Midwifery Womens Health. 2005;50:507-516.

COMMENTARY

Examining nurses' decision process for medication management in home care.

Kovner C, Menezes J, Goldberg JD. Jt Comm J Qual Patient Saf. 2005;31:379-385.

STUDY

Detection and prevention of medication errors using real-time bedside nurse charting.

Nelson NC, Evans RS, Samore MH, Gardner RM. J Am Med Inform Assoc. 2005;12:390-397.

STUDY

Computerized physician order entry with clinical decision support in the long-term care setting: insights from the Baycrest Centre for Geriatric Care.

Rochon PA, Field TS, Bates DW, et al. J Am Geriatr Soc. 2005;53:1780-1789.

STUDY

Electronic prescribing improves medication safety in community-based office practices.

Kaushal R, Kern LM, Barrón Y, Quaresimo J, Abramson EL. J Gen Intern Med. 2010;25:530-536.

COMMENTARY

Impatient Inpatient Dosing

White RH. AHRQ WebM&M [serial online]. July/August 2005.

STUDY

A randomized trial of electronic clinical reminders to improve medication laboratory monitoring.

Matheny ME, Sequist TD, Seger AC, et al. J Am Med Inform Assoc. 2008;15:424-429.

STUDY

Injury and liability associated with monitored anesthesia care: a closed claims analysis.

Bhananker SM, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB. Anesthesiology. 2006;104:228-234.

NEWSPAPER/MAGAZINE ARTICLE

FDA Advise-ERR: prevent dangerous drug-device interaction causing falsely elevated glucose levels.

ISMP Medication Safety Alert! Acute Care Edition. June 19, 2008;13:1-3.

COMMENTARY

Is the Admission Drug Dose Too Low?

Kaushal R, Abramson E. AHRQ WebM&M [serial online]. August 2009.

STUDY

Academic detailing to improve laboratory testing among outpatient medication users.

Lafata JE, Gunter MJ, Hsu J, et al. Med Care. 2007;45:966-972.