AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (63)

•Diagnostic Errors (108)

•Identification Errors (63)

•Discontinuities, Gaps, and Hand-Off Problems (103)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (364)

•Medical Complications (61)

•Nonsurgical Procedural Complications (32)

•Surgical Complications (103)

•Transfusion Complications (7)

•Psychological and Social Complications (27)

Origin/Sponsor

•Australia and New Zealand (28)

•Central and South America (4)

•Europe (122)

•North America (516)

Resource Types

•Audiovisual (9)

•Book/Report (23)

•Clinical Guideline (2)

•Journal Article (573)

•Legislation/Regulation (5)

•Meeting/Conference (3)

•Newspaper/Magazine Article (90)

•Press Release/Announcement (11)

•Special or Theme Issue (7)

•Tools/Toolkit (6)

•Web Resource (9)

Error Types
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Active Errors

•Noncognitive Errors ("Slips & Lapses") (75)

•Cognitive Errors ("Mistakes") (69)

Approach to Improving Safety

•Quality Improvement Strategies (190)

•Legal and Policy Approaches (75)

•Error Reporting and Analysis (205)

•Communication Improvement (226)

•Human Factors Engineering (185)

•Teamwork (38)

•Specialization of Care (39)

•Logistical Approaches (48)

•Culture of Safety (71)

•Technologic Approaches (198)

•Education and Training (185)

Clinical Areas

•Allied Health Services (7)

•Medicine (576)

•Nursing (87)

•Pharmacy (117)

Target Audience

•Health Care Providers (627)

•Health Care Executives and Administrators (557)

•Non-Health Care Professionals (267)

•Patients (55)

Setting of Care

•Hospitals (507)

•Psychiatric Facilities (4)

•Residential Facilities (15)

•Ambulatory Care (89)

•Outpatient Surgery (13)

•Patient Transport (11)

1 - 20 of 740

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BOOK/REPORT

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.

Toft B. London, England: Department of Health; 2001.

COMMENTARY

Dangerous Shift

Patterson ES. AHRQ WebM&M [serial online]. November 2008.

COMMENTARY

Moving Pains

Schell H, Wachter RM. AHRQ WebM&M [serial online]. July 2006.

COMMENTARY

Wrong Route for Nutrients

Scott-Cawiezell JR, AHRQ WebM&M [serial online]. July 2008.

COMMENTARY

On the Other Hand

Henneman EA. AHRQ WebM&M [serial online]. May 2007.

STUDY

Time-dependent drug–drug interaction alerts in care provider order entry: software may inhibit medication error reductions.

van der Sijs H, Lammers L, van den Tweel A, et al. J Am Med Inform Assoc. 2009;16:864-868.

STUDY

Automated drug dispensing system reduces medication errors in an intensive care setting.

Chapuis C, Roustit M, Bal G, et al. Crit Care Med. 2010;38:2275-2281.

COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors associated with documented allergies.

PA-PSRS Patient Saf Advis. September 2008;5:75-80.

PRESS RELEASE/ANNOUNCEMENT

Serious medication errors from intravenous administration of nimodipine oral capsules.

MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; August 2, 2010.

STUDY

Competence and certification of registered nurses and safety of patients in intensive care units.

Kendall-Gallagher D, Blegen MA. Am J Crit Care. 2009;18:106-113.

STUDY

Errors in administration of parenteral drugs in intensive care units: multinational prospective study.

Valentin A, Capuzzo M, Guidet B, et al; Research Group on Quality Improvement of the European Society of Intensive Care Medicine (ESICM); Sentinel Events Evaluation (SEE) Study Investigators. BMJ. 2009;338:b814.

STUDY

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people.

Barber ND, Alldred DP, Raynor DK, et al. Qual Saf Health Care. 2009;18:341-346.

NEWSPAPER/MAGAZINE ARTICLE

Don't underestimate the impact of change on risk potential.

ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.

STUDY

Computerized order entry with limited decision support to prevent prescription errors in a PICU.

Kadmon G, Bron-Harlev E, Nahum E, Schiller O, Haski G, Shonfeld T. Pediatrics. 2009;124:945-950.

COMMENTARY

Where’s the Feeding Tube?

Metheny MA., Meert KL, AHRQ WebM&M [serial online]. September 2008.

NEWSPAPER/MAGAZINE ARTICLE

Too many abandon the "second victims" of medical errors.

ISMP Medication Safety Alert! Acute Care Edition. July 14, 2011;16:1-3.

BOOK/REPORT

Vincristine: Learning from Error Workshop.

World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2008.

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.

COMMENTARY classic

classic

Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.

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