AHRQ Patient Safety Network

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•Device-related Complications (6)

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•Identification Errors (4)

•Discontinuities, Gaps, and Hand-Off Problems (12)

•Medication Safety (43)

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•Special or Theme Issue (1)

•Tools/Toolkit (2)

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•Epidemiology of Errors and Adverse Events (7)

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Approach to Improving Safety
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Reminders

Clinical Areas

•Medicine (44)

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Target Audience

•Health Care Providers (52)

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•Hospitals (27)

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1 - 20 of 62

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TOOLKIT

ISMP and FDA campaign to eliminate use of error-prone abbreviations.

Huntington Valley, PA: Institute for Safe Medication Practices.

STUDY

Medication prescribing errors involving the route of administration.

Lesar TS. Hosp Pharm. 2006;41:1053-1066.

COMMENTARY

Citrate Mix-Up

Weber RJ. AHRQ WebM&M [serial online]. May 2006.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing vincristine administration errors.

The Joint Commission. Sentinel Event Alert. July 14, 2005;(34):1-3.

NEWSPAPER/MAGAZINE ARTICLE

Generic drug names: fertile ground for errors?

Wynn P. Drug Topics Supplements. August 8, 2005.

STUDY

A trial of automated decision support alerts for contraindicated medications using computerized physician order entry.

Galanter WL, Didomenico RJ, Polikaitis A. J Am Med Inform Assoc. 2005;12:269-274.

STUDY

Evaluation of the implementation of the alert issued by the UK National Patient Safety Agency on the storage and handling of potassium chloride concentrate solution.

Lankshear AJ, Sheldon TA, Lowson KV, Watt IS, Wright J. Qual Saf Health Care. 2005;14:196-201.

COMMENTARY

Safe medication prescribing and monitoring in the outpatient setting.

Shojania KG. CMAJ. 2006;174:1257-1258.

NEWSPAPER/MAGAZINE ARTICLE

USP initiatives for the safe use of medical gases.

Zaidi K, Curry PD Jr, Becker SC. Pharmaceutical Technology. November 2, 2005;29:102-103.

COMMENTARY

A Troubling Amine

Flynn EA. AHRQ WebM&M [serial online]. September 2006.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion #546: tracking and reminder systems.

ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2012;120:1535-1537.

MULTI-USE WEBSITE

"Save Lives Now" project.

Hospitals and Health Networks.

PRESS RELEASE/ANNOUNCEMENT

Heparin sodium injection 10,000 units/mL, and HEP-LOCK U/P 10 units/mL medication errors.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 6, 2007.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:844-847.

STUDY

Using nurses and office staff to report prescribing errors in primary care.

Kennedy AG, Littenberg B, Senders JW. Int J Qual Health Care. 2008;20:238-245.

PRESS RELEASE/ANNOUNCEMENT

Safety warnings regarding use of fentanyl transdermal (skin) patches.

FDA Public Health Advisory. Silver Spring, MD: US Food and Drug Administration; December 21, 2007.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:940-945.

NEWSPAPER/MAGAZINE ARTICLE

CPOE: it don't come easy.

Anderson HJ. Health Data Manag. January 1, 2009;17:18.

PRESS RELEASE/ANNOUNCEMENT

FDA public health notification: MRI-caused injuries in patients with implanted neurological stimulators.

Schultz DG. Rockville, MD: Center for Devices and Radiological Health, Food and Drug Administration; May 10, 2005.

COMMENTARY

The Dangerous Detour.

Gibson J, Taylor D. AHRQ WebM&M [serial online]. June 2003.

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