AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (70)

•Diagnostic Errors (6)

•Identification Errors (2)

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

•Medication Safety (57)

•Medical Complications (9)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (8)

•Transfusion Complications (1)

Origin/Sponsor

•Africa (1)

•Asia (2)

•Australia and New Zealand (3)

•Central and South America (1)

Resource Types

•Journal Article (73)

•Legislation/Regulation (4)

•Newspaper/Magazine Article (26)

•Press Release/Announcement (4)

•Special or Theme Issue (1)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (14)

•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 (64)

•Nursing (18)

•Pharmacy (23)

Target Audience

•Health Care Providers (83)

•Health Care Executives and Administrators (77)

•Non-Health Care Professionals (67)

•Patients (14)

Setting of Care

•Hospitals (62)

•Residential Facilities (3)

•Ambulatory Care (7)

•Outpatient Surgery (1)

1 - 20 of 117

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COMMENTARY

Morphine overdose from error propagation on an acute pain service: [Une surdose de morphine resultant de multiples erreurs dans un service de douleur aigue].

Syed S, Paul JE, Hueftlein M, Kampf M, McLean RF. Can J Anaesth. 2006;53:586-590.

COMMENTARY

New technology, new errors: how to prime an upgrade of an insulin infusion pump.

Rule AM, Drincic A, Galt KA. Jt Comm J Qual Patient Saf. 2007;33:155-162.

COMMENTARY

Improving safety throughout the medication use process in a neonatal intensive care unit.

Asdigha MN. Hosp Pharm. 2006;41:1067-1075.

ORGANIZATIONAL POLICY/GUIDELINES

Tubing misconnections—a persistent and potentially deadly occurrence.

Sentinel Event Alert. April 3, 2006;(36):1-3.

NEWSPAPER/MAGAZINE ARTICLE

Double key bounce and double keying errors.

ISMP Medication Safety Alert! Acute Care Edition. January 12, 2006;11:1-2.

COMMENTARY

Intravenous medication safety and smart infusion systems: lessons learned and future opportunities.

Keohane CA, Hayes J, Saniuk C, Rothschild JM, Bates DW. J Infus Nurs. 2005;28:321-328.

NEWSPAPER/MAGAZINE ARTICLE

Latest heparin fatality speaks loudly—what have you done to stop the bleeding?

ISMP Medication Safety Alert! April 8, 2010;15:1-3.

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.

STUDY

Intravenous infusion safety technology: return on investment.

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

STUDY

Application of the IV Medication Harm Index to assess the nature of harm averted by "smart" infusion safety systems.

Williams CK, Maddox RR, Heape E, et al. J Patient Saf. 2006;2:132-139.

COMMENTARY

Not again!

Berwick DM. BMJ. 2001;322:247-248.

NEWSPAPER/MAGAZINE ARTICLE

Fatal gas line mix-up: How to avoid making this "gastly" mistake.

ISMP Medication Safety Alert! Acute Care Edition. December 16, 2004;9:1-2.

COMMENTARY

Wrong Route for Nutrients

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

NEWSPAPER/MAGAZINE ARTICLE

M.R.I.'s strong magnets cited in accidents.

McNeil DG Jr. New York Times. August 19, 2005;National Desk section:1.

REVIEW

Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients.

Johnson JR, Kuskowski MA, Wilt TJ. Ann Intern Med. 2006;144:116-126.

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.

ORGANIZATIONAL POLICY/GUIDELINES

Error-avoidance recommendations for tubing misconnections when using luer-tip connectors: a statement by the USP Safe Medication Use Expert Committee.

Simmons D, Phillips MS, Grissinger M, Becker SC. Jt Comm J Qual Patient Saf. 2008;34:293-296.

COMMENTARY

ISMP medication error report analysis.

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

COMMENTARY

Hidden Mystery.

Brunette DD. AHRQ WebM&M [serial online]. March 2005.

COMMENTARY

Smart pumps: advanced capabilities and continuous quality improvement.

Vanderveen T. Patient Saf Quality Healthc. January/February 2007.

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