AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (16)

•Diagnostic Errors (26)

•Identification Errors (8)

•Discontinuities, Gaps, and Hand-Off Problems (31)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (100)

•Medical Complications (51)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (32)

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•Asia (12)

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•Journal Article (236)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (23)

•Special or Theme Issue (2)

•Tools/Toolkit (6)

•Web Resource (1)

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•Epidemiology of Errors and Adverse Events (103)

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•Latent Errors (22)

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Approach to Improving Safety
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Audit and Feedback

Clinical Areas

•Allied Health Services (1)

•Medicine (202)

•Nursing (14)

•Pharmacy (33)

Target Audience

•Health Care Providers (195)

•Health Care Executives and Administrators (255)

•Non-Health Care Professionals (93)

•Patients (11)

Setting of Care

•Hospitals (208)

•Residential Facilities (6)

•Ambulatory Care (27)

•Outpatient Surgery (6)

•Patient Transport (1)

1 - 20 of 284

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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.

NEWSPAPER/MAGAZINE ARTICLE

As industry automates, adverse events continue to haunt caregivers.

Wetzel TG. Health Data Manage. 2011 Feb;19:86, 88, 90 passim.

STUDY

Uncomfortable prescribing decisions in hospitals: the impact of teamwork.

Lewis PJ, Tully MP. J R Soc Med. 2009;102:481-488.

BOOK/REPORT

An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.

Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.

STUDY

Trauma resuscitation errors and computer-assisted decision support.

Fitzgerald M, Cameron P, Mackenzie C, et al. Arch Surg. 2011;146:218-225.

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

Optimising surgical training: use of feedback to reduce errors during a simulated surgical procedure.

Boyle E, Al-Akash M, Gallagher AG, Traynor O, Hill AD, Neary PC. Postgrad Med J. 2011;87:524-528.

STUDY

Adverse drug event rates in six community hospitals and the potential impact of computerized physician order entry for prevention.

Hug BL, Witkowski DJ, Sox CM, et al. J Gen Intern Med. 2010;25:31-38.

STUDY

Medication errors with electronic prescribing (eP): two views of the same picture.

Savage I, Cornford T, Klecun E, Barber N, Clifford S, Franklin BD. BMC Health Serv Res. 2010;10:135.

NEWSPAPER/MAGAZINE ARTICLE

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.

COMMENTARY

Development of the Leapfrog methodology for evaluating hospital implemented inpatient computerized physician order entry systems.

Kilbridge PM, Welebob EM, Classen DC. Qual Saf Health Care. 2006;15:81-84.

STUDY

Preventable and non-preventable adverse drug events in hospitalized patients: a prospective chart review in the Netherlands.

Dequito AB, Mol PG, van Doormaal JE, et al. Drug Saf. 2011;34:1089-1100.

NEWSPAPER/MAGAZINE ARTICLE

Common cause analysis.

Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.

STUDY

Development of a core drug list towards improving prescribing education and reducing errors in the UK.

Baker E, Roberts AP, Wilde K, et al. Br J Clin Pharmacol. 2011;71:190-198.

COMMENTARY

Do Not Disturb!

Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.

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

Antimicrobial prescription errors in hospitalized children: role of antimicrobial stewardship program in detection and intervention.

Di Pentima MC, Chan S, Eppes SC, Klein JD. Clin Pediatr (Phila). 2009;53:715-723e1.

STUDY

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.

STUDY

Rethinking resident supervision to improve safety: from hierarchical to interprofessional models.

Tamuz M, Giardina TD, Thomas EJ, Menon S, Singh H. J Hosp Med. 2011;6:448-456.

STUDY

Medication errors recovered by emergency department pharmacists.

Rothschild JM, Churchill W, Erickson A, et al. Ann Emerg Med. 2010;55:513-521.

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