AHRQ Patient Safety Network

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•Device-related Complications (33)

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•Discontinuities, Gaps, and Hand-Off Problems (100)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (444)

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•Epidemiology of Errors and Adverse Events (200)

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Approach to Improving Safety
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Technologic Approaches

•Automatic drug dispensers (36)

•Bar Coding and Radiofrequency ID Tagging (92)

•Computerized Adverse Event Detection (95)

•Computer-Assisted Therapy (9)

•Telemedicine (10)

•Clinical Information Systems (423)

Clinical Areas

•Allied Health Services (2)

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Target Audience

•Health Care Providers (634)

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1 - 20 of 861

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COMMENTARY

Patient safety in the context of neonatal intensive care: research and educational opportunities.

Raju TN, Suresh G, Higgins RD. Pediatr Res. 2011;70:109-115.

SPECIAL OR THEME ISSUE

Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit.

Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(suppl 6):S83-S264.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety: the synergy of technology and behavior.

Yarbrough C, Rypkema S. Patient Safety & Quality Healthcare. January-February 2008;5:32-35.

NEWSPAPER/MAGAZINE ARTICLE

Another tragic parenteral nutrition compounding error.

ISMP Medication Safety Alert! Acute Care Edition. April 21, 2011;16:1-3.

SPECIAL OR THEME ISSUE

Patient safety and quality in the pediatric intensive care unit.

Pediatr Crit Care Med. 2007;8(suppl):S1-S43.

STUDY

Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study.

Morriss FH Jr, Abramowitz PW, Nelson SP, et al. J Pediatr. 2009;197:678-685.

STUDY

Fall prevention in acute care hospitals: a randomized trial.

Dykes PC, Carroll DL, Hurley A, et al. JAMA. 2010;304:1912-1918.

BOOK/REPORT

Coordination Between Emergency and Primary Care Physicians.

Carrier E, Yee T, Holtzwart RA. Washington, DC: National Institute for Health Care Reform; 2011.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety in the ED.

Scalise D, Lazar C. Hosp Health Netw. May 2006:80:5,48,2.

STUDY

Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement.

Render ML, Hasselbeck R, Freyberg RW, Hofer TP, Sales AE, Almenoff PL; VA ICU Clinical Advisory Group. BMJ Qual Saf. 2011;20:725-732.

STUDY

Risk of adverse drug events in neonates treated with opioids and the effect of a bar-code–assisted medication administration system.

Morriss FH, Jr, Abramowitz PW, Nelson SP, Milavetz G, Michael SL, Gordon SN. Am J Health Syst Pharm. 2011;68:57-62.

STUDY

Prevalence of adverse events in pediatric intensive care units in the United States.

Agarwal S, Classen D, Larsen G, et al. Pediatr Crit Care Med. 2010;11:568-578.

STUDY

Prevalence of copied information by attendings and residents in critical care progress notes.

Thornton JD, Schold JD, Venkateshaiah L, Lander B. Crit Care Med. 2013;41:382-388.

NEWSPAPER/MAGAZINE ARTICLE

Don't underestimate the impact of change on risk potential.

ISMP Medication Safety Alert! Acute Care Edition. September 11, 2008;13:1-3.

STUDY

Increasing medication error reporting rates while reducing harm through simultaneous cultural and system-level interventions in an intensive care unit.

Abstoss KM, Shaw BE, Owens TA, Juno JL, Commiskey EL, Niedner MF. BMJ Qual Saf. 2011;914-922.

STUDY

Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration.

Yamamoto L, Kanemori J. Am J Emerg Med. 2010;28:588-592.

MEETING/CONFERENCE PROCEEDINGS

Making the Health Care System Safer Through Implementation and Innovation.

Agency for Healthcare Research and Quality. Kaisernetwork.org Web site. June 8, 2005.

BOOK/REPORT

Patient Safety.

Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.

COMMENTARY

Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy.

Bellandi T, Albolino S, Tartaglia R, Filipponi F. Transplant Proc. 2010;42:2187-2189.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing maternal death.

Sentinel Event Alert. January 26, 2010;(44):1-4.

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