AHRQ Patient Safety Network

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PATIENT SAFETY PRIMERS
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Adverse Events after Hospital Discharge

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Safety Target

•Device-related Complications (67)

•Diagnostic Errors (104)

•Identification Errors (55)

•Discontinuities, Gaps, and Hand-Off Problems (158)

•Fatigue and Sleep Deprivation (26)

•Medication Safety (568)

•Medical Complications (178)

•Nonsurgical Procedural Complications (22)

•Surgical Complications (193)

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•Australia and New Zealand (42)

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•Audiovisual (4)

•Book/Report (38)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (247)

•Legal and Policy Approaches (66)

•Error Reporting and Analysis (529)

•Communication Improvement (235)

•Human Factors Engineering (130)

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•Education and Training (172)

Clinical Areas

•Allied Health Services (3)

•Dentistry (1)

•Medicine (1072)

•Nursing (111)

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Target Audience

•Health Care Providers (1019)

•Health Care Executives and Administrators (1030)

•Non-Health Care Professionals (375)

•Patients (57)

Setting of Care

•Hospitals (935)

•Psychiatric Facilities (6)

•Residential Facilities (40)

•Ambulatory Care (177)

•Outpatient Surgery (20)

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1 - 20 of 1326

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STUDY

Chemotherapy medication errors in a pediatric cancer treatment center: prospective characterization of error types and frequency and development of a quality improvement initiative to lower the error rate.

Watts RG, Parsons K. Pediatr Blood Cancer. 2013 Mar 20; [Epub ahead of print].

STUDY

Medication errors in the home: a multisite study of children with cancer.

Walsh KE, Roblin DW, Weingart SN, et al. Pediatrics. 2013;131:e1405-e1414.

STUDY

Polypharmacy in hospitalized older adult cancer patients: experience from a prospective, observational study of an oncology-acute care for elders unit.

Flood KL, Carroll MB, Le CV, Brown CJ. Am J Geriatr Pharmacother. 2009;7:151-158.

STUDY

Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model.

White RE, Trbovich PL, Easty AC, Savage P, Trip K, Hyland S. Qual Saf Health Care. 2010;19:562-567.

STUDY

High performance teamwork training and systems redesign in outpatient oncology.

Bunnell CA, Gross AH, Weingart SN, et al. BMJ Qual Saf. 2013;22:405-413.

STUDY

Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety.

Collins CM, Elsaid KA. Int J Qual Health Care. 2011;23:36-43.

STUDY

Medication errors involving oral chemotherapy.

Weingart SN, Toro J, Spencer J, et al. Cancer. 2010;116:2455-2464.

STUDY

Characteristics of pediatric chemotherapy medication errors in a national error reporting database.

Rinke ML, Shore AD, Morlock L, Hicks RW, Miller MR. Cancer. 2007;110:186-195.

STUDY

Chemotherapy safety and severe adverse events in cancer patients: strategies to efficiently avoid chemotherapy errors in in- and outpatient treatment.

Markert A, Thierry V, Kleber M, Behrens M, Engelhardt M. Int J Cancer. 2009;124:722-728.

STUDY

The role of advice in medication administration errors in the pediatric ambulatory setting.

Lemer C, Bates DW, Yoon C, Keohane C, Fitzmaurice G, Kaushal R. J Patient Saf. 2009;5:168-175.

REVIEW

Monitoring for medication errors in outpatient settings.

Balkrishnan R, Foss CE, Pawaskar M, Uhas AA, Feldman SR. J Dermatolog Treat. 2009;20:229-232.

STUDY

Parents' medication administration errors: role of dosing instruments and health literacy.

Yin HS, Mendelsohn AL, Wolf MS, et al. Arch Pediatr Adolesc Med. 2010;164:181-186.

STUDY

Oral outpatient chemotherapy medication errors in children with acute lymphoblastic leukemia.

Taylor JA, Winter L, Geyer LJ, Hawkins DS. Cancer. 2006;107:1400-1406.

STUDY

Medication errors in paediatric outpatients.

Kaushal R, Goldmann DA, Keohane CA, et al. Qual Saf Health Care. 2010;19:e30.

STUDY

Injection practices among clinicians in United States health care settings.

Pugliese G, Gosnell C, Bartley JM, Robinson S. Am J Infect Control. 2010;38:789-798.

STUDY

Are opioid dependence and methadone maintenance treatment (MMT) documented in the medical record? A patient safety issue.

Walley AY, Farrar D, Cheng DM, Alford DP, Samet JH. J Gen Intern Med. 2009;24:1007-1011.

STUDY

Oncology medication safety: a 3D status report 2008.

Johnson PE, Chambers CR, Vaida AJ. J Oncol Pharm Pract. 2008;14:169-180.

STUDY

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Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.

STUDY

Medication administration errors in assisted living: scope, characteristics, and the importance of staff training.

Zimmerman S, Love K, Sloane PD, Cohen LW, Reed D, Carder PC; Center for Excellence in Assisted Living-University of North Carolina Collaborative. J Am Geriatr Soc. 2011;59:1060-1068.

STUDY

Safety hazards in cancer care: findings using three different methods.

Lipczak H, Knudsen JL, Nissen A. BMJ Qual Saf. 2011;20:1052-1056.

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