AHRQ Patient Safety Network

The Collection > Computerized Adverse Event Detection

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Safety Target

•Device-related Complications (4)

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•Identification Errors (1)

•Discontinuities, Gaps, and Hand-Off Problems (10)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (92)

•Medical Complications (18)

•Nonsurgical Procedural Complications (2)

•Surgical Complications (7)

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•Psychological and Social Complications (1)

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•Newspaper/Magazine Article (17)

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•Special or Theme Issue (1)

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Error Types

•Epidemiology of Errors and Adverse Events (40)

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Approach to Improving Safety
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Computerized Adverse Event Detection

Clinical Areas

•Medicine (92)

•Nursing (7)

•Pharmacy (33)

Target Audience

•Health Care Providers (92)

•Health Care Executives and Administrators (101)

•Non-Health Care Professionals (95)

•Patients (1)

Setting of Care

•Hospitals (75)

•Residential Facilities (2)

•Ambulatory Care (21)

•Outpatient Surgery (2)

1 - 20 of 127

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STUDY

Time-dependent drug–drug interaction alerts in care provider order entry: software may inhibit medication error reductions.

van der Sijs H, Lammers L, van den Tweel A, et al. J Am Med Inform Assoc. 2009;16:864-868.

STUDY

Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation.

Merry AF, Webster CS, Hannam J, et al. BMJ. 2011;343:d5543.

COMMENTARY

Eptifibatide Epilogue

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

REVIEW

What evidence supports the use of computerized alerts and prompts to improve clinicians' prescribing behavior?

Schedlbauer A, Prasad V, Mulvaney C, et al. J Am Med Inform Assoc. 2009;16:531-538.

NEWSPAPER/MAGAZINE ARTICLE

Multiple latent failures align to allow a serious drug interaction to harm a patient.

ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.

COMMENTARY

Double Dosing, by the Rules

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

COMMENTARY

Sick and Pregnant

El-Ibiary S. AHRQ WebM&M [serial online]. November 2008.

NEWSPAPER/MAGAZINE ARTICLE

Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.

ISMP Medication Safety Alert! Acute Care Edition. August 26, 2010;15:1-3.

STUDY

Bar code medication administration technology: characterization of high-alert medication triggers and clinician workarounds.

Miller DF, Fortier CR, Garrison KL. Ann Pharmacother. 2011;45:162-168.

STUDY

Critical drug–drug interactions for use in electronic health records systems with computerized physician order entry: review of leading approaches.

Classen DC, Phansalkar S, Bates DW. J Patient Saf. 2011;7:61-65.

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

Randomized trial to improve prescribing safety during pregnancy.

Raebel MA, Carroll NM, Kelleher JA, Chester EA, Berga S, Magid DJ. J Am Med Inform Assoc. 2007;14:440-450.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors occurring with the use of bar-code administration technology.

PA-PSRS Patient Saf Advis. December 2008;5:122-126.

STUDY

The impact of prescribing safety alerts for elderly persons in an electronic medical record: an interrupted time series evaluation.

Smith DH, Perrin N, Feldstein A, et al. Arch Intern Med. 2006;166:1098-1104.

STUDY

Overrides of medication alerts in ambulatory care.

Isaac T, Weissman JS, Davis RB, et al. Arch Intern Med. 2009;169:305-311.

COMMENTARY

Medication Overdose.

Kaushal R. AHRQ WebM&M [serial online]. April 2003.

STUDY

Impact of health information technology on detection of potential adverse drug events at the ordering stage.

Roberts LL, Ward MM, Brokel JM, Wakefield DS, Crandall DK, Conlon P. Am J Health Syst Pharm. 2010;67:1838-1846.

STUDY

An empirical model to estimate the potential impact of medication safety alerts on patient safety, health care utilization, and cost in ambulatory care.

Weingart SN, Simchowitz B, Padolsky H, et al. Arch Intern Med. 2009;169;1465-1473.

STUDY

A framework for evaluating the appropriateness of clinical decision support alerts and responses.

McCoy AB, Waitman LR, Lewis JB, et al. J Am Med Inform Assoc. 2012;19:346-352.

COMMENTARY

Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work?

Peterson J. AHRQ WebM&M [serial online]. May 2008

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