AHRQ Patient Safety Network

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•Device-related Complications (16)

•Diagnostic Errors (29)

•Identification Errors (8)

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

•Fatigue and Sleep Deprivation (4)

•Medication Safety (101)

•Medical Complications (51)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (31)

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•Asia (10)

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•Journal Article (244)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (24)

•Special or Theme Issue (2)

•Tools/Toolkit (5)

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•Epidemiology of Errors and Adverse Events (101)

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Approach to Improving Safety
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Audit and Feedback

Clinical Areas

•Allied Health Services (1)

•Medicine (207)

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Target Audience

•Health Care Providers (194)

•Health Care Executives and Administrators (259)

•Non-Health Care Professionals (96)

•Patients (11)

Setting of Care

•Hospitals (209)

•Residential Facilities (6)

•Ambulatory Care (31)

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1 - 20 of 291

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STUDY

Medication errors recovered by emergency department pharmacists.

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

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.

REVIEW

Systematic review of medication safety assessment methods.

Meyer-Massetti C, Cheng CM, Schwappach DL, et al. Am J Health Syst Pharm. 2011;68:227-240.

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

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

Improving resident engagement in quality improvement and patient safety initiatives at the bedside: the Advocate for Clinical Education (ACE).

Schleyer AM, Best JA, McIntyre LK, Ehrmantraut R, Calver P, Goss JR. Am J Med Qual. 2012 Aug 20; [Epub ahead of print].

NEWSPAPER/MAGAZINE ARTICLE

Common cause analysis.

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

STUDY

What is the measure of a safe hospital? Medication errors missed by risk management, clinical staff, and surveyors.

Grasso BC, Rothschild JM, Jordan CW, Jayaram G. J Psychiatr Pract. 2005;11:268-273.

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

An inpatient fall prevention initiative in a tertiary care hospital.

Weinberg J, Proske D, Szerszen A, et al. Jt Comm J Qual Patient Saf. 2011;37:317-325.

NEWSPAPER/MAGAZINE ARTICLE

The Leapfrog Group's CPOE standard and evaluation tool.

Metzger JB, Welebob E, Turisco F, Classen DC. Patient Saf Qual Healthc. July/August 2008;5:22-25.

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

Implementing peer evaluation of handoffs: associations with experience and workload.

Arora VM, Greenstein EA, Woodruff JN, Staisiunas PG, Farnan JM. J Hosp Med. 2013;8:132-136.

BOOK/REPORT

Adverse Events in Hospitals: Methods for Identifying Events.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; March 2010. Report No. OEI-06-08-00221.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:730-733.

COMMENTARY

I-CaRe: a case review tool focused on improving inpatient care.

Huang Lee J, Vidyarthi AR, Sehgal NL, Auerbach AD, Wachter RM. Jt Comm J Qual Patient Saf. 2009;35:115-119.

MEASUREMENT TOOL/INDICATOR

Medication Safety Self Assessment for Automated Dispensing Cabinets.

Horsham, PA: Institute for Safe Medication Practices; 2009.

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.

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.

STUDY

Physician implicit review to identify preventable errors during in-hospital cardiac arrest.

Jain R, Kuhn L, Repaskey W, et al. Arch Intern Med. 2011;171:89-90.

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