AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (75)

•Diagnostic Errors (101)

•Identification Errors (39)

•Discontinuities, Gaps, and Hand-Off Problems (185)

•Fatigue and Sleep Deprivation (72)

•Medication Safety (696)

•Medical Complications (119)

•Nonsurgical Procedural Complications (34)

•Surgical Complications (186)

•Transfusion Complications (3)

•Psychological and Social Complications (65)

Origin/Sponsor
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United States of America

•United States Federal Government (59)

•State Governments and Agencies (5)

Resource Types

•Audiovisual (17)

•Award (1)

•Book/Report (46)

•Clinical Guideline (9)

•Journal Article (1300)

•Legislation/Regulation (43)

•Meeting/Conference (8)

•Newsletter/Journal (6)

•Newspaper/Magazine Article (215)

•Press Release/Announcement (18)

•Special or Theme Issue (22)

•Tools/Toolkit (29)

•Web Resource (27)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (321)

•Active Errors (228)

•Latent Errors (79)

•Near Miss (28)

Approach to Improving Safety

•Quality Improvement Strategies (462)

•Legal and Policy Approaches (129)

•Error Reporting and Analysis (413)

•Communication Improvement (385)

•Human Factors Engineering (190)

•Teamwork (108)

•Specialization of Care (122)

•Logistical Approaches (182)

•Culture of Safety (167)

•Technologic Approaches (313)

•Education and Training (342)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (1701)

•Health Care Executives and Administrators (1167)

•Non-Health Care Professionals (457)

•Patients (101)

Setting of Care

•Hospitals (929)

•Psychiatric Facilities (1)

•Residential Facilities (21)

•Ambulatory Care (184)

•Outpatient Surgery (16)

•Patient Transport (3)

1 - 20 of 1742

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REVIEW

Adverse events associated with sedatives, analgesics, and other drugs that provide patient comfort in the intensive care unit.

Riker RR, Fraser GL. Pharmacotherapy. 2005;25:8S-18S.

NEWSPAPER/MAGAZINE ARTICLE

Promethazine conundrum: IV can hurt more than IM injection!

ISMP Medication Safety Alert! Acute Care Edition. November 2, 2006;11:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Paralyzed by mistakes: preventing errors with neuromuscular blocking agents.

ISMP Medication Safety Alert! Acute Care Edition. September 22, 2005;10:1-3.

STUDY

Potentially inappropriate prescribing in elderly veterans: are we using the wrong drug, wrong dose, or wrong duration?

Pugh MJ, Fincke BG, Bierman AS, et al. J Am Geriatr Soc. 2005;53:1282-1289.

STUDY

Risk factors for adverse drug events: a 10-year analysis.

Evans RS, Lloyd JF, Stoddard GJ, Nebeker JR, Samore MH. Ann Pharmacother. 2005;39:1161-1168.

TOOLKIT

ISMP and FDA campaign to eliminate use of error-prone abbreviations.

Huntington Valley, PA: Institute for Safe Medication Practices.

NEWSPAPER/MAGAZINE ARTICLE

Clear liquids may place patients at risk.

PA-PSRS Patient Saf Advis. December 2005;2:29-31.

STUDY

Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin.

Donihi AC, DiNardo MM, DeVita MA, Korytkowski MT. Qual Saf Health Care. 2006;15:89-91.

FACT SHEET/FAQS

Oral Dosage Forms that Should Not Be Crushed.

Mitchell JF. Institute for Safe Medication Practices.

TOOLKIT

Looking Collectively at Risk.

Pathways for Medication Safety Tool #2. Chicago, IL: American Hospital Association; 2003.

NEWSPAPER/MAGAZINE ARTICLE

IV potassium given epidurally: getting to the "route" of the problem.

ISMP Medication Safety Alert! Acute Care Edition. April 6, 2006;11:1-2.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing vincristine administration errors.

The Joint Commission. Sentinel Event Alert. July 14, 2005;(34):1-3.

STUDY

Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes.

Alexander KP, Chen AY, Roe MT, et al; CRUSADE Investigators. JAMA. 2005;294:3108-3116.

COMMENTARY

Medication safety: look-alike/sound-alike drugs in home care.

Friedman MM. Home Healthc Nurse. 2005;23:243-253.

NEWSPAPER/MAGAZINE ARTICLE

Accuracy at every step: the challenge of medication reconciliation.

Institute for Healthcare Improvement Web site. March 20, 2006.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:725-728.

NEWSPAPER/MAGAZINE ARTICLE

Tablet splitting: Do it only if you "half" to, and then do it safely.

ISMP Medication Safety Alert! Acute Care Edition. May 18, 2006;11:1-2.

FACT SHEET/FAQS

Medication safety issue brief. Bar code implementation strategies.

American Hospital Association, American Society of Health-System Pharmacists, Hospitals and Health Networks. Hosp Health Netw. July 2005;79:65-66.

COMMENTARY

Improving safety throughout the medication use process in a neonatal intensive care unit.

Asdigha MN. Hosp Pharm. 2006;41:1067-1075.

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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