AHRQ Patient Safety Network

The Collection > Medical Device Design

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Safety Target

•Device-related Complications (75)

•Diagnostic Errors (6)

•Identification Errors (2)

•Discontinuities, Gaps, and Hand-Off Problems (3)

•Medication Safety (50)

•Medical Complications (10)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (8)

•Transfusion Complications (1)

Origin/Sponsor

•Africa (1)

•Asia (2)

•Australia and New Zealand (2)

•Central and South America (1)

Resource Types

•Journal Article (69)

•Legislation/Regulation (4)

•Newspaper/Magazine Article (25)

•Press Release/Announcement (5)

•Special or Theme Issue (1)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (13)

•Active Errors (34)

•Latent Errors (21)

•Near Miss (2)

Approach to Improving Safety
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Medical Device Design

Clinical Areas

•Allied Health Services (3)

•Medicine (65)

•Nursing (16)

•Pharmacy (20)

Target Audience

•Health Care Providers (81)

•Health Care Executives and Administrators (78)

•Non-Health Care Professionals (70)

•Patients (13)

Setting of Care

•Hospitals (64)

•Residential Facilities (2)

•Ambulatory Care (7)

•Outpatient Surgery (1)

1 - 20 of 114

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COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

NEWSPAPER/MAGAZINE ARTICLE

ALERT: reports of severe harm after intravenous administration of breast milk to infants.

ISMP Canada Safety Bulletin. July 31, 2011;11:1-2.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

NEWSPAPER/MAGAZINE ARTICLE

Preventing catheter/tubing misconnections: much needed help is on the way.

ISMP Medication Safety Alert! Acute Care Edition. July 15, 2010;15:1-2.

STUDY

Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications.

Yin HS, Wolf MS, Dreyer BP, Sanders LM, Parker RM. JAMA. 2010;304:2595-2602.

PRESS RELEASE/ANNOUNCEMENT

Safety Investigation of CT Brain Perfusion Scans: Update 11/9/2010.

Rockville, MD: US Food and Drug Administration; November 9, 2010.

COMMENTARY

Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.

Lum TE, Fairbanks RJ, Pennington EC, Zwemer FL. Acad Emerg Med. 2005;12:658-662.

NEWSPAPER/MAGAZINE ARTICLE

Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.

ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Radiation offers new cures, and ways to do harm.

Bogdanich W. New York Times. January 24, 2010:A1.

ORGANIZATIONAL POLICY/GUIDELINES

Radiation risks of diagnostic imaging.

Sentinel Event Alert #47. August 24, 2011.

REVIEW

Enteral feeding misconnections: an update.

Guenter P, Hicks RW, Simmons D. Nutr Clin Pract. 2009;24:325-334.

COMMENTARY

Eptifibatide Epilogue

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

COMMENTARY

Where’s the Feeding Tube?

Metheny MA., Meert KL, AHRQ WebM&M [serial online]. September 2008.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:654-657.

NEWSPAPER/MAGAZINE ARTICLE

Considering insulin pens for routine hospital use? Consider this...

ISMP Medication Safety Alert! Acute Care Edition. May 8, 2008;13:1-3.

COMMENTARY

Wrong Route for Nutrients

Scott-Cawiezell JR, AHRQ WebM&M [serial online]. July 2008.

STUDY

Novel analysis of clinically relevant diagnostic errors in point-of-care devices.

Shermock KM, Streiff MB, Pinto BL, Kraus P, Pronovost PJ. J Thromb Haemost. 2011;9:1769-1775.

REVIEW

Inappropriate trust in technology: implications for critical care nurses.

Browne M, Cook P. Nurs Crit Care. 2011;16:92-98.

COMMENTARY

Lethal Cap.

Schillinger D. AHRQ WebM&M [serial online]. March 2004.

STUDY

Impact of a comprehensive safety initiative on patient-controlled analgesia errors.

Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.

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