AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (3)

•Diagnostic Errors (2)

•Identification Errors (4)

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

•Medication Safety (41)

•Medical Complications (4)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (1)

•Transfusion Complications (1)

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•Journal Article (37)

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•Newspaper/Magazine Article (11)

•Press Release/Announcement (4)

•Special or Theme Issue (1)

•Tools/Toolkit (2)

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Error Types

•Epidemiology of Errors and Adverse Events (7)

•Active Errors (16)

•Latent Errors (6)

•Near Miss (1)

Approach to Improving Safety
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Reminders

Clinical Areas

•Medicine (39)

•Nursing (3)

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Target Audience

•Health Care Providers (47)

•Health Care Executives and Administrators (37)

•Non-Health Care Professionals (24)

•Patients (2)

Setting of Care

•Hospitals (21)

•Residential Facilities (1)

•Ambulatory Care (14)

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1 - 20 of 59

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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

Medication prescribing errors involving the route of administration.

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

NEWSPAPER/MAGAZINE ARTICLE

CPOE: it don't come easy.

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

STUDY

Tiering drug–drug interaction alerts by severity increases compliance rates.

Paterno MD, Maviglia SM, Gorman PN, et al. J Am Med Inform Assoc. 2009;16:40-46.

STUDY

An empirical model to estimate the potential impact of medication safety alerts on patient safety, health care utilization, and cost in ambulatory care.

Weingart SN, Simchowitz B, Padolsky H, et al. Arch Intern Med. 2009;169;1465-1473.

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.

STUDY

A randomized trial of electronic clinical reminders to improve medication laboratory monitoring.

Matheny ME, Sequist TD, Seger AC, et al. J Am Med Inform Assoc. 2008;15:424-429.

COMMENTARY

Around the Block.

Minichiello T. AHRQ WebM&M [serial online]. March 2005.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing vincristine administration errors.

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

STUDY

Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care.

Lo HG, Matheny ME, Seger DL, Bates DW, Gandhi TK. J Am Med Inform Assoc. 2009;16:66-71.

COMMENTARY

Color coding to reduce errors.

Deboer S, Seaver M, Broselow J. Am J Nurs. 2005;105:68-71.

MULTI-USE WEBSITE

"Save Lives Now" project.

Hospitals and Health Networks.

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.

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.

STUDY

Timely follow-up of abnormal outpatient test results: perceived barriers and impact on patient safety.

Moore C, Saigh O, Trikha A, Lin JJ. J Patient Saf. 2008;4:241-244.

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.

STUDY

Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge.

Schnipper JL, Liang CL, Hamann C, et al. J Am Med Inform Assoc. 2011;18:309-313.

NEWSPAPER/MAGAZINE ARTICLE

Selling soap.

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

COMMENTARY

An unsuspected MR projectile: a "wooden" chair with metal bracing.

Ulaner GA, Colletti PM. J Magn Reson Imaging. 2006;23:781-782.

NEWSPAPER/MAGAZINE ARTICLE

Generic drug names: fertile ground for errors?

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

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