AHRQ Patient Safety Network

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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.

TOOLKIT

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

Huntington Valley, PA: Institute for Safe Medication Practices.

COMMENTARY

A Troubling Amine

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

NEWSPAPER/MAGAZINE ARTICLE

Rx for a better prescription. Hospital bans doctors from using confusing medical abbreviations.

Hall J. The Free Lance-Star. September 25, 2005.

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.

COMMENTARY

ISMP medication error report analysis.

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

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.

STUDY

Impact of implementing alerts about medication black-box warnings in electronic health records.

Yu DT, Seger DL, Lasser KE, et al. Pharmacoepidemiol Drug Saf. 2011;20:192-202.

COMMENTARY

Safe medication prescribing and monitoring in the outpatient setting.

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

COMMENTARY

Shake Well.

Flynn EA. AHRQ WebM&M [serial online]. September 2003.

STUDY

Use of a computerized forcing function improves performance in ordering restraints.

Griffey RT, Wittels K, Gilboy N, McAfee AT. Ann Emerg Med. 2009;53:469-476.

NEWSPAPER/MAGAZINE ARTICLE

Selling soap.

Dubner SJ, Levitt SD. New York Times Magazine. September 24, 2006:22.

NEWSPAPER/MAGAZINE ARTICLE

Reducing patient harm from opiates.

ISMP Medication Safety Alert! Acute Care Edition. February 22, 2007;12:1-3.

STUDY

Mixed results in the safety performance of computerized physician order entry.

Metzger J, Welebob E, Bates DW, Lipsitz S, Classen DC. Health Aff (Millwood). 2010;29:655-663.

STUDY

Improved pain resolution in hospitalized patients through targeting of pain mismanagement as medical error.

Okon TR, Lutz PS, Liang H. J Pain Symptom Manage. 2009;37:1039-1049.

NEWSPAPER/MAGAZINE ARTICLE

Fatal misadministration of IV vincristine.

ISMP Medication Safety Alert! Acute Care Edition. December 1, 2005;10:1-2, 4.

NEWSPAPER/MAGAZINE ARTICLE

IV vincristine survey shows safety improvements needed.

ISMP Medication Safety Alert! Acute Care Edition. February 23, 2006;11:1-2.

STUDY

Emergency medical services system changes reduce pediatric epinephrine dosing errors in the prehospital setting.

Kaji AH, Gausche-Hill M, Conrad H, et al. Pediatrics. 2006;118:1493-1500.

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