AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (55)

•Diagnostic Errors (56)

•Identification Errors (25)

•Discontinuities, Gaps, and Hand-Off Problems (139)

•Fatigue and Sleep Deprivation (66)

•Medication Safety (272)

•Medical Complications (113)

•Nonsurgical Procedural Complications (36)

•Surgical Complications (136)

•Transfusion Complications (5)

•Psychological and Social Complications (59)

Origin/Sponsor

•Africa (2)

•Asia (20)

•Australia and New Zealand (35)

•Central and South America (2)

Resource Types

•Clinical Guideline (1)

•Journal Article (869)

•Legislation/Regulation (10)

•Meeting/Conference (15)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (106)

•Press Release/Announcement (9)

•Special or Theme Issue (23)

•Tools/Toolkit (18)

•Web Resource (51)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (197)

•Active Errors (181)

•Latent Errors (56)

•Near Miss (21)

Approach to Improving Safety
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Education and Training

•Students (112)

•Residents and Fellows (271)

•Continuing Education (43)

•Online Education (26)

•Simulators (138)

•Teamwork Training (128)

•Patient Education (106)

Clinical Areas

•Allied Health Services (7)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (794)

•Health Care Executives and Administrators (863)

•Non-Health Care Professionals (716)

•Patients (82)

Setting of Care

•Hospitals (738)

•Psychiatric Facilities (2)

•Residential Facilities (15)

•Ambulatory Care (68)

•Outpatient Surgery (7)

•Patient Transport (6)

1 - 20 of 1185

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STUDY

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.

STUDY

Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.

Walker PC, Bernstein SJ, Tucker Jones JN, et al. Arch Intern Med. 2009;169:2003-2010.

STUDY

Reducing potentially fatal errors associated with high doses of insulin: a successful multifaceted multidisciplinary prevention strategy.

Dooley MJ, Wiseman M, McRae A, et al. BMJ Qual Saf. 2011;20:637-644.

COMMENTARY

Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge.

Murphy EM, Oxencis CJ, Klauck JA, Meyer DA, Zimmerman JM. Am J Health Syst Pharm. 2009;66:2126-2131.

STUDY

Antecedents of severe and nonsevere medication errors.

Chang YK, Mark BA. J Nurs Scholarsh. 2009;41:70-78.

COMMENTARY

ISMP medication error report analysis.

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

AUDIOVISUAL PRESENTATION

When things go wrong.

Institute for Healthcare Improvement. Campaign Live. August 18, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

STUDY

Reducing clinical errors in cancer education: interpreter training.

Gany FM, Gonzalez CJ, Basu G, et al. J Cancer Educ. 2010;25:560-564.

STUDY

Medication errors recovered by emergency department pharmacists.

Rothschild JM, Churchill W, Erickson A, et al. Ann Emerg Med. 2010;55:513-521.

STUDY

Cognitive errors detected in anaesthesiology: a literature review and pilot study.

Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Br J Anaesth. 2012;108:229-235.

STUDY

Work-arounds and artifacts during transition to a computer physician order entry: what they are and what they mean.

Schoville RR. J Nurs Care Qual. 2009;24:316-324.

REVIEW

The novice nurse and clinical decision-making: how to avoid errors.

Saintsing D, Gibson LM, Pennington AW. J Nurs Manag. 2011;19:354-359.

STUDY

Attitudes toward medical device use errors and the prevention of adverse events.

Johnson TR, Tang X, Graham MJ, et al. Jt Comm J Qual Patient Saf. 2007;33:689-694.

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

Toward learning from patient safety reporting systems.

Pronovost PJ, Thompson DA, Holzmueller CG, et al. J Crit Care. 2006;21:305-315.

COMMENTARY

Using incident reporting to improve patient safety: a conceptual model.

Pronovost PJ, Holzmueller CG, Young J, et al. J Patient Saf. 2007;3:27-33.

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.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

FACT SHEET/FAQS

Medication safety issue brief. Counterfeit drug prevention and identification.

American Hospital Association, American Society of Health-System Pharmacists, Hospitals and Health Networks. Hosp Health Netw. August 2005;79.29-30.

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