AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (36)

•Diagnostic Errors (34)

•Identification Errors (24)

•Discontinuities, Gaps, and Hand-Off Problems (83)

•Fatigue and Sleep Deprivation (9)

•Medication Safety (146)

•Medical Complications (26)

•Nonsurgical Procedural Complications (13)

•Surgical Complications (44)

•Transfusion Complications (3)

•Psychological and Social Complications (11)

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•Africa (1)

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•Australia and New Zealand (9)

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•Clinical Guideline (1)

•Journal Article (291)

•Legislation/Regulation (7)

•Meeting/Conference (1)

•Newspaper/Magazine Article (70)

•Press Release/Announcement (5)

•Special or Theme Issue (4)

•Tools/Toolkit (3)

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Latent Errors

Approach to Improving Safety

•Quality Improvement Strategies (92)

•Legal and Policy Approaches (69)

•Error Reporting and Analysis (133)

•Communication Improvement (112)

•Human Factors Engineering (108)

•Teamwork (23)

•Specialization of Care (11)

•Logistical Approaches (53)

•Culture of Safety (75)

•Technologic Approaches (91)

•Education and Training (72)

Clinical Areas

•Allied Health Services (5)

•Medicine (284)

•Nursing (62)

•Pharmacy (62)

Target Audience

•Health Care Providers (293)

•Health Care Executives and Administrators (309)

•Non-Health Care Professionals (178)

•Patients (50)

Setting of Care

•Hospitals (274)

•Psychiatric Facilities (1)

•Residential Facilities (11)

•Ambulatory Care (43)

•Outpatient Surgery (4)

•Patient Transport (4)

1 - 20 of 425

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COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:547-550, 554.

COMMENTARY 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.

NEWSPAPER/MAGAZINE ARTICLE

Barcode technology flaws put some patients at risk.

US News & World Report. July 3, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

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

Epidural-IV route mix-ups: reducing the risk of deadly errors.

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

SPECIAL OR THEME ISSUE

Special Issue: Patient Safety.

Ergonomics. 2006;49:439-630.

STUDY

Evaluation of causes and frequency of medication errors during information technology downtime.

Hanuscak TL, Szeinbach SL, Seoane-Vazquez E, Reichert BJ, McCluskey CF. Am J Health Syst Pharm. 2009;66:1119-1124.

COMMENTARY

Crossed Coverage

Kayser SR. AHRQ WebM&M [serial online]. February 2007.

STUDY

Operational failures and interruptions in hospital nursing.

Tucker AL, Spear SJ. Health Serv Res. 2006;41:643-662.

STUDY

Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents.

Redwood S, Rajakumar A, Hodson J, Coleman JJ. BMC Med Inform Decis Mak. 2011;11:29.

STUDY

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.

Staggers N, Clark L, Blaz JW, Kapsandoy S. Health Informatics J. 2011;17:209-223.

REVIEW

Work interruptions and their contribution to medication administration errors: an evidence review.

Biron AD, Loiselle CG, Lavoie-Tremblay M. Worldviews Evid Based Nurs. 2009;6:70-86.

COMMENTARY

Wrong Route for Nutrients

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

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.

FACT SHEET/FAQS classic

Preventing Medication Errors: A $21 Billion Opportunity.

Washington, DC: National Priorities Partnership and National Quality Forum; December 2010.

STUDY

Using a multi-method, user centred, prospective hazard analysis to assess care quality and patient safety in a care pathway.

Dean J, Hutchinson A, Hamilton Escoto K, Lawson R. BMC Health Serv Res. 2007;7:89.

NEWSPAPER/MAGAZINE ARTICLE

Inquiry into reporter's death finds multiple failures in care.

Stout D. New York Times. June 17, 2006;National desk:9.

STUDY

The nurse's role in the causation of compensable injury.

Painter LM, Dudjak LA, Kidwell KM, Simmons RL, Kidwell RP. J Nurs Care Qual. 2011;4:311-319.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

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