AHRQ Patient Safety Network

The Collection > United States of America

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Safety Target

•Device-related Complications (148)

•Diagnostic Errors (162)

•Identification Errors (102)

•Discontinuities, Gaps, and Hand-Off Problems (366)

•Fatigue and Sleep Deprivation (76)

•Medication Safety (1028)

•Medical Complications (357)

•Nonsurgical Procedural Complications (96)

•Surgical Complications (349)

•Transfusion Complications (14)

•Psychological and Social Complications (121)

Origin/Sponsor
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United States of America

•United States Federal Government (189)

•State Governments and Agencies (18)

Resource Types

•Clinical Guideline (10)

•Journal Article (2317)

•Legislation/Regulation (60)

•Meeting/Conference (28)

•Newsletter/Journal (12)

•Newspaper/Magazine Article (342)

•Press Release/Announcement (37)

•Special or Theme Issue (46)

•Tools/Toolkit (62)

•Web Resource (96)

•Grant (10)

Error Types

•Epidemiology of Errors and Adverse Events (676)

•Active Errors (493)

•Latent Errors (197)

•Near Miss (59)

Approach to Improving Safety

•Quality Improvement Strategies (902)

•Legal and Policy Approaches (299)

•Error Reporting and Analysis (853)

•Communication Improvement (798)

•Human Factors Engineering (453)

•Teamwork (276)

•Specialization of Care (211)

•Logistical Approaches (233)

•Culture of Safety (428)

•Technologic Approaches (598)

•Education and Training (665)

Clinical Areas

•Allied Health Services (9)

Target Audience

•Health Care Providers (2730)

•Health Care Executives and Administrators (2657)

•Non-Health Care Professionals (1206)

•Patients (260)

Setting of Care

•Hospitals (1881)

•Psychiatric Facilities (13)

•Residential Facilities (62)

•Ambulatory Care (363)

•Outpatient Surgery (40)

•Patient Transport (23)

1 - 20 of 3283

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COMMENTARY

Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine?

Reddy GK, Brown B, Nanda A. Clin Neurol Neurosurg. 2011;113:68-71.

STUDY

Medication errors among adults and children with cancer in the outpatient setting.

Walsh KE, Dodd KS, Seetharaman K, et al. J Clin Oncol. 2009;27:891-896.

BOOK/REPORT

Fluorouracil Incident Root Cause Analysis Report.

Toronto, ON, Canada: Institute for Safe Medication Practices Canada. May 8, 2007.

NEWSPAPER/MAGAZINE ARTICLE

IV vincristine survey shows safety improvements needed.

ISMP Medication Safety Alert! Acute Care Edition. February 23, 2006;11:1-2.

STUDY

Medication errors in paediatric outpatients.

Kaushal R, Goldmann DA, Keohane CA, et al. Qual Saf Health Care. 2010;19:e30.

STUDY

The impact of drug shortages on children with cancer—the example of mechlorethamine.

Metzger ML, Billett A, Link MP. N Engl J Med. 2012;367:2461-2463.

STUDY

High performance teamwork training and systems redesign in outpatient oncology.

Bunnell CA, Gross AH, Weingart SN, et al. BMJ Qual Saf. 2013;22:405-413.

STUDY

Chemotherapy medication errors in a pediatric cancer treatment center: prospective characterization of error types and frequency and development of a quality improvement initiative to lower the error rate.

Watts RG, Parsons K. Pediatr Blood Cancer. 2013 Mar 20; [Epub ahead of print].

BOOK/REPORT

Toward Improving the Outcome of Pregnancy: Enhancing Perinatal Health Through Quality, Safety and Performance Initiatives (TIOP III).

Berns SD, ed. White Plains, NY: March of Dimes; December 2010.

STUDY

Interruption handling strategies during paediatric medication administration.

Colligan L, Bass EJ. BMJ Qual Saf. 2012;21:912-917.

NEWSPAPER/MAGAZINE ARTICLE

Good intention, uncertain outcome...our take on physician dispensing in offices and clinics.

ISMP Medication Safety Alert! Acute Care Edition. March 8, 2012;17:1-3.

COMMENTARY

Chemotherapy in home care: one team's performance improvement journey toward reducing medication errors.

Ewen BM, Combs R, Popelas C, Faraone GM. Home Healthc Nurse. 2012;30:28-37.

NEWSPAPER/MAGAZINE ARTICLE

Fatal misadministration of IV vincristine.

ISMP Medication Safety Alert! Acute Care Edition. December 1, 2005;10:1-2, 4.

COMMENTARY

Decreasing patient misidentification before chemotherapy administration.

Spruill A, Eron B, Coghill A, Talbert G. Clin J Oncol Nurs. 2009;13:716-717.

STUDY

The You CAN campaign: teamwork training for patients and families in ambulatory oncology.

Weingart SN, Simchowitz B, Kahlert Eng T, et al. Jt Comm J Qual Patient Saf. 2009;35:63-71.

STUDY

Process of care failures in breast cancer diagnosis.

Weingart SN, Saadeh MG, Simchowitz B, et al. J Gen Intern Med. 2009;24:702-709.

CALIFORNIA MEETING/CONFERENCE

2013 Current & Emerging Issues Symposium.

Organization for Safety, Asepsis and Prevention. June 13–15, 2013; Hyatt Regency Mission Bay Spa & Marina, San Diego, CA.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:844-847.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing vincristine administration errors.

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

STUDY

Risk of mistaken DNR orders.

Rohrer JE, Esler WV, Saeed Q, et al. Support Care Cancer. 2006;14:871-873.

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