AHRQ Patient Safety Network

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•Device-related Complications (2)

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•Hospitals (21)

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COMMENTARY

Around the Block.

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

STUDY

Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial.

Strom BL, Schinnar R, Aberra F, et al. Arch Intern Med. 2010;170:1578-1583.

STUDY

Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error?

Coleman JJ, Hemming K, Nightingale PG, et al. J R Soc Med. 2011;104:208-218.

COMMENTARY

Medication orders are written clearly and transcribed accurately – implementing Medication Management Standard 3.20 and National Patient Safety Goal 2b.

Laselle TJ,May SK. Hosp Pharm. 2006;41:82-87.

STUDY

Management of test results in family medicine offices.

Elder NC, McEwen TR, Flach JM, Gallimore JJ. Ann Fam Med. 2009;7:343-351.

COMMENTARY

Eptifibatide Epilogue

Churchill WW, Fiumara K. AHRQ WebM&M [serial online]. April 2009.

COMMENTARY

Too Tight Control.

Rubin HR, Fajtova VT. AHRQ WebM&M [serial online]. May 2004.

COMMENTARY

Forgotten Med.

Cucina R. AHRQ WebM&M [serial online]. April 2005.

COMMENTARY

Staying safe: simple tools for safe surgery.

Karl RC. Bull Am Coll Surg. April 2007;92:16-22.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors associated with documented allergies.

PA-PSRS Patient Saf Advis. September 2008;5:75-80.

COMMENTARY

A proactive risk avoidance system using failure mode and effects analysis for "same-name" physician orders.

Tarpey K, Schaaf E, Lakhani U, Balcitis J. Jt Comm J Qual Patient Saf. 2010;36:461-467.

STUDY

Errors with concentrated epinephrine in otolaryngology.

Shah RK, Hoy E, Roberson DW, Nielsen D. Laryngoscope. 2008 Nov; 118: 1928-30.

COMMENTARY

Moved Too Soon.

Lindenauer P. AHRQ WebM&M [serial online]. October 2004.

COMMENTARY

"Superficial" Report Leads to "Deep" Problem.

Dhaliwal G. AHRQ WebM&M [serial online]. December 2009.

COMMENTARY

Thin Air.

Gaba DM. AHRQ WebM&M [serial online]. October 2004.

STUDY

Identifying opportunities for quality improvement in surgical site infection prevention.

Gagliardi AR, Eskicioglu C, McKenzie M, Fenech D, Nathens A, McLeod R. Am J Infect Control. 2009;37:398-402.

MEETING/CONFERENCE PROCEEDINGS

July 2011 Author in the Room Teleconference.

Schiff GD. Institute for Healthcare Improvement; Journal of the American Medical Association. July 20, 2011.

COMMENTARY

Double Dosing, by the Rules

Cohen H. AHRQ WebM&M [serial online]. February/March 2009.

COMMENTARY

Use of the common gas outlet for supplementary oxygen during Caesarean section.

Edsell ME, Erasmus PD. Anaesthesia. 2005;60:1152-1153.

REVIEW

What have we learned about interventions to reduce medical errors?

Woodward HI, Mytton OT, Lemer C, et al. Annu Rev Public Health. 2010;31:479-497.

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