AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (51)

•Diagnostic Errors (52)

•Identification Errors (22)

•Discontinuities, Gaps, and Hand-Off Problems (119)

•Fatigue and Sleep Deprivation (33)

•Medication Safety (242)

•Medical Complications (103)

•Nonsurgical Procedural Complications (35)

•Surgical Complications (101)

•Transfusion Complications (5)

•Psychological and Social Complications (41)

Origin/Sponsor

•Australia and New Zealand (49)

•Central and South America (4)

•Europe (137)

•North America (624)

Resource Types

•Audiovisual (9)

•Book/Report (56)

•Journal Article (619)

•Legislation/Regulation (6)

•Meeting/Conference (14)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (65)

•Press Release/Announcement (10)

•Special or Theme Issue (16)

•Tools/Toolkit (14)

•Web Resource (40)

Error Types

•Epidemiology of Errors and Adverse Events (194)

•Active Errors (192)

•Latent Errors (64)

•Near Miss (20)

Approach to Improving Safety
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Education and Training

•Students (26)

•Residents and Fellows (143)

•Continuing Education (28)

•Online Education (13)

•Simulators (82)

•Teamwork Training (72)

•Patient Education (83)

Clinical Areas

•Allied Health Services (5)

•Complementary and Alternative Medicine (1)

•Dentistry (1)

•Medicine (589)

•Nursing (96)

•Pharmacy (91)

Target Audience

•Health Care Providers (671)

•Health Care Executives and Administrators (677)

•Non-Health Care Professionals (438)

•Patients (53)

Setting of Care

•Hospitals (583)

•Psychiatric Facilities (2)

•Residential Facilities (16)

•Ambulatory Care (65)

•Outpatient Surgery (6)

•Patient Transport (8)

1 - 20 of 858

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NEWSPAPER/MAGAZINE ARTICLE

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.

STUDY

Therapeutic errors involving adults in the community setting: nature, causes and outcomes.

Taylor DM, Robinson J, MacLeod D, MacBean CE, Braitberg G. Aust N Z J Public Health. 2009;33:388-394.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:847-853.

COMMENTARY

A Mid-Summer Fog

Braddock CH. AHRQ WebM&M [serial online]. November 2008.

REVIEW

Year in review: medication mishaps in the elderly.

Peron EP, Marcum ZA, Boyce R, Hanlon JT, Handler SM. Am J Geriatr Pharmacother. 2011;9:1-10.

REVIEW

"Tech-check-tech": a review of the evidence on its safety and benefits.

Adams AJ, Martin SJ, Stolpe SF. Am J Health Syst Pharm. 2011;68:1824-1833.

STUDY

classic

A July spike in fatal medication errors: a possible effect of new medical residents.

Phillips DP, Barker GEC. J Gen Intern Med. 2010;25:774-779.

REVIEW

An international review of patient safety measures in radiotherapy practice.

Shafiq J, Barton M, Noble D, Lemer C, Donaldson LJ. Radiother Oncol. 2009;92:15-21.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2013.

COMMENTARY

Safer out of hours primary care.

Cosford PA, Thomas JM. BMJ. 2010;340:c3194.

STUDY

Medication administration errors in assisted living: scope, characteristics, and the importance of staff training.

Zimmerman S, Love K, Sloane PD, Cohen LW, Reed D, Carder PC; Center for Excellence in Assisted Living-University of North Carolina Collaborative. J Am Geriatr Soc. 2011;59:1060-1068.

PRESS RELEASE/ANNOUNCEMENT

Serious medication errors from intravenous administration of nimodipine oral capsules.

MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; August 2, 2010.

STUDY

Improving medication error reporting in hospice care.

Boyer R, McPherson ML, Deshpande G, Smith SW. Am J Hosp Palliat Care. 2009;26:361-367.

STUDY

Psychiatry morbidity and mortality rounds: implementation and impact.

Goldman S, Demaso DR, Kemler B. Acad Psychiatry. 2009;33:383-388.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:696–698.

STUDY

The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium.

Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog J; Pediatric Sedation Research Consortium. Anesth Analg. 2009;108:795-804.

REVIEW

Patient safety in geriatrics: a call for action.

Tsilimingras D, Rosen AK, Berlowitz DR. J Gerontol A Biol Sci Med Sci. 2003;58:M813-M819.

STUDY

The impact of trained assistance on error rates in anaesthesia: a simulation-based randomised controlled trial.

Weller JM, Merry AF, Robinson BJ, Warman GR, Janssen A. Anaesthesia. 2009;64:126-130.

STUDY

Ambulance personnel perceptions of near misses and adverse events in pediatric patients.

Cushman JT, Fairbanks RJ, O'Gara KG, et al. Prehosp Emerg Care. 2010;14:477-484.

STUDY

Medication errors and response bias: the tip of the iceberg.

Bar-Oz B, Goldman M, Lahat E, et al. Isr Med Assoc J. 2008;10:771-774.

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