AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (58)

•Diagnostic Errors (146)

•Identification Errors (71)

•Discontinuities, Gaps, and Hand-Off Problems (98)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (415)

•Medical Complications (73)

•Nonsurgical Procedural Complications (34)

•Surgical Complications (137)

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•Psychological and Social Complications (34)

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•Australia and New Zealand (28)

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Active Errors

•Noncognitive Errors ("Slips & Lapses") (71)

•Cognitive Errors ("Mistakes") (123)

Approach to Improving Safety

•Quality Improvement Strategies (209)

•Legal and Policy Approaches (99)

•Error Reporting and Analysis (258)

•Communication Improvement (242)

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•Teamwork (34)

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•Technologic Approaches (200)

•Education and Training (180)

Clinical Areas

•Allied Health Services (6)

•Dentistry (1)

•Medicine (673)

•Nursing (88)

•Pharmacy (153)

Target Audience

•Health Care Providers (702)

•Health Care Executives and Administrators (641)

•Non-Health Care Professionals (276)

•Patients (108)

Setting of Care

•Hospitals (579)

•Psychiatric Facilities (3)

•Residential Facilities (13)

•Ambulatory Care (125)

•Outpatient Surgery (17)

•Patient Transport (12)

1 - 20 of 892

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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

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.

STUDY

Determinants of patient-reported medication errors: a comparison among seven countries.

Lu CY, Roughead E. Int J Clin Pract. 2011;65:733-740.

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.

STUDY

Safety on an inpatient pediatric otolaryngology service: many small errors, few adverse events.

Shah RK, Lander L, Forbes P, Jenkins K, Healy GB, Roberson DW. Laryngoscope. 2009;119:871-879.

STUDY

Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.

Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.

STUDY

Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers.

Spiller HA, Borys DJ, Ryan ML, Sawyer TS, Wilson BL. Ann Pharmacother. 2011;45:17-22.

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.

STUDY

ED overcrowding is associated with an increased frequency of medication errors.

Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. Am J Emerg Med. 2010;28:304-309.

STUDY

Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system.

Mattison MLP, Afonso KA, Ngo LH, Mukamal KJ. Arch Intern Med. 2010;170:1331-1336.

STUDY

Pediatric antidepressant medication errors in a national error reporting database.

Rinke ML, Bundy DG, Shore AD, Colantuoni E, Morlock LL, Miller MR. J Dev Behav Pediatr. 2010;31:129-136.

STUDY

Wrong-site sinus surgery in otolaryngology.

Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.

COMMENTARY

Reducing the risk of adverse drug events in older adults.

Pretorius RW, Gataric G, Swedlund SK, Miller JR. Am Fam Physician. 2013;87:331-336.

STUDY

Medication errors involving oral chemotherapy.

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

STUDY

Comparison of computerized surveillance and manual chart review for adverse events.

Tinoco A, Evans RS, Staes CJ, Lloyd JF, Rothschild JM, Haug PJ. J Am Med Inform Assoc. 2011;18:491-497.

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.

STUDY

Medication discrepancies upon hospital to skilled nursing facility transitions.

Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. J Gen Intern Med. 2009;24:630-635.

STUDY

Transitioning between electronic health records: effects on ambulatory prescribing safety.

Abramson EL, Malhotra S, Fischer K, et al. J Gen Intern Med. 2011;26:868-874.

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.

NEWSPAPER/MAGAZINE ARTICLE

ISMP updates its list of drug name pairs with Tall man letters.

ISMP Medication Safety Alert! Acute Care Edition. November 18, 2010;15:1-3.

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