Computerized Adverse Event Detection
PATIENT SAFETY PRIMERS
Device-related Complications (4)
Diagnostic Errors (9)
Discontinuities, Gaps, and Hand-Off Problems (12)
Fatigue and Sleep Deprivation (1)
Medication Safety (100)
Medical Complications (19)
Nonsurgical Procedural Complications (2)
Surgical Complications (11)
Transfusion Complications (1)
Psychological and Social Complications (1)
Australia and New Zealand (3)
North America (126)
Journal Article (115)
Newspaper/Magazine Article (24)
Press Release/Announcement (1)
Special or Theme Issue (2)
Epidemiology of Errors and Adverse Events (47)
Active Errors (35)
Latent Errors (13)
Approach to Improving Safety
Computerized Adverse Event Detection
Health Care Providers (94)
Health Care Executives and Administrators (110)
Non-Health Care Professionals (89)
Setting of Care
Residential Facilities (2)
Ambulatory Care (24)
Outpatient Surgery (4)
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ISMP medication error report analysis.
Cohen MC. Hosp Pharm. 2009;44:374-378.
Shakespeare was on target—don't be a borrower or lender.
ISMP Medication Safety Alert! Acute Care Edition. November 19, 2009;14:1-3.
SPECIAL OR THEME ISSUE
Patient safety and quality in the pediatric intensive care unit.
Pediatr Crit Care Med. 2007;8(suppl):S1-S43.
Baby's death spotlights safety risks linked to computerized systems.
Graham J, Dizikes C. Chicago Tribune. June 27, 2011.
Potentially fatal errors with GDH-PQQ [glucose dehydrogenase pyrroloquinoline quinone] glucose monitoring technology.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 13, 2009.
Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.
Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.
Common cause analysis.
Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.
Medication errors occurring with the use of bar-code administration technology.
PA-PSRS Patient Saf Advis. December 2008;5:122-126.
Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.
Tham E, Calmes HM, Poppy A, et al. Pediatrics. 2011;128:e438-e445.
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.
On the Other Hand
Henneman EA. AHRQ WebM&M [serial online]. May 2007.
Active surveillance using electronic triggers to detect adverse events in hospitalized patients.
Szekendi MK, Sullivan C, Bobb A, et al. Qual Saf Health Care. 2006;15:184-190.
Development of trigger tools for surveillance of adverse events in ambulatory surgery.
Kaafarani HM, Rosen AK, Nebeker JR, et al. Qual Saf Health Care. 2010;19:425-429.
Neuromuscular blocking agents: reducing associated wrong-drug errors.
PA-PSRS Patient Saf Advis. December 2009;6:109-114.
Outpatient adverse drug events identified by screening electronic health records.
Gandhi TK, Seger AC, Overhage JM, et al. J Patient Saf. 2010;6;91-96.
Medication safety in acute care in Australia: where are we now? Part 2: a review of strategies and activities for improving medication safety 2002-2008.
Semple SJ, Roughead EE. Aust New Zealand Health Policy. 2009;6:24.
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.
Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system.
Mattison MLP, Afonso KA, Ngo LH, Mukamal KJ. Arch Intern Med. 2010;170:1331-1336.
'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured.
Classen DC, Resar R, Griffin F, et al. Health Aff (Millwood). 2011;30:581-589.
Preventing maternal death.
Sentinel Event Alert. January 26, 2010;(44):1-4.
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