AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (78)

•Diagnostic Errors (6)

•Identification Errors (2)

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

•Medication Safety (55)

•Medical Complications (9)

•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 (74)

•Legislation/Regulation (4)

•Newspaper/Magazine Article (27)

•Press Release/Announcement (6)

•Special or Theme Issue (1)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (16)

•Active Errors (35)

•Latent Errors (21)

•Near Miss (2)

Approach to Improving Safety
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Medical Device Design

Clinical Areas

•Allied Health Services (3)

•Medicine (67)

•Nursing (18)

•Pharmacy (20)

Target Audience

•Health Care Providers (84)

•Health Care Executives and Administrators (82)

•Non-Health Care Professionals (75)

•Patients (14)

Setting of Care

•Hospitals (63)

•Residential Facilities (3)

•Ambulatory Care (6)

•Outpatient Surgery (1)

1 - 20 of 123

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COMMENTARY

ISMP medication error report analysis.

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

STUDY

Intravenous infusion safety technology: return on investment.

Danello SH, Maddox RR, Schaack GJ. Hosp Pharm. 2009;44:680-687, 696.

COMMENTARY

Eptifibatide Epilogue

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

COMMENTARY

ISMP medication error report analysis.

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

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:960-964.

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.

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.

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.

NEWSPAPER/MAGAZINE ARTICLE

Experts offer smart tips for smart pumps.

Gebhart F. Drug Topics (Health-System Edition). July 23, 2007.

COMMENTARY

The Role of Bar Coding and Smart Pumps in Safety

Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN AHRQ WebM&M [serial online]. September 2008.

STUDY

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2008.

Pedersen CA, Schneider P, Scheckelhoff DJ. Am J Health Syst Pharm. 2009;66:926-946.

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

Pharmaceutical industry and medical device companies: part of the solution?

ISMP Medication Safety Alert! Acute Care Edition. November 16, 2006;11:1, 3.

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

An extra dose of safety.

Health Manage Techol. April 2007;28:30-32, 34.

STUDY

The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.

Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. Qual Saf Health Care. 2010;19:430-434.

NEWSPAPER/MAGAZINE ARTICLE

Heparin: improving treatment and reducing risk of harm.

Daner WE, Gosselin RC, Raschke R, Vanderveen T. Patient Saf Qual Healthcare. January/February 2009;6:20-25.

STUDY

Enhancing patient safety with intelligent intravenous infusion devices: experience in a specialty cardiac hospital.

Wood JL, Burnette JS. Heart Lung. 2012;41:173-176.

AUDIOVISUAL

Software glitches pose new, potentially dangerous problems for medical devices.

Kennedy D. "iHealthBeat." California Healthcare Foundation. July 25, 2008.

REVIEW

Tubing misconnections: normalization of deviance.

Simmons D, Symes L, Guenter P, Graves K. Nutr Clin Pract. 2011;26:286-293.

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