AHRQ Patient Safety Network

The Collection > United States of America

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Safety Target

•Device-related Complications (162)

•Diagnostic Errors (161)

•Identification Errors (116)

•Discontinuities, Gaps, and Hand-Off Problems (462)

•Fatigue and Sleep Deprivation (96)

•Medication Safety (1254)

•Medical Complications (458)

•Nonsurgical Procedural Complications (97)

•Surgical Complications (388)

•Transfusion Complications (20)

•Psychological and Social Complications (148)

Origin/Sponsor
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United States of America

•United States Federal Government (257)

•State Governments and Agencies (31)

Resource Types

•Clinical Guideline (7)

•Journal Article (2706)

•Legislation/Regulation (57)

•Meeting/Conference (34)

•Newsletter/Journal (11)

•Newspaper/Magazine Article (490)

•Press Release/Announcement (29)

•Special or Theme Issue (55)

•Tools/Toolkit (68)

•Web Resource (108)

•Grant (9)

Error Types

•Epidemiology of Errors and Adverse Events (843)

•Active Errors (548)

•Latent Errors (245)

•Near Miss (68)

Approach to Improving Safety

•Quality Improvement Strategies (947)

•Legal and Policy Approaches (407)

•Error Reporting and Analysis (1079)

•Communication Improvement (948)

•Human Factors Engineering (497)

•Teamwork (312)

•Specialization of Care (272)

•Logistical Approaches (294)

•Culture of Safety (529)

•Technologic Approaches (708)

•Education and Training (747)

Clinical Areas

•Allied Health Services (9)

Target Audience

•Health Care Providers (2883)

•Health Care Executives and Administrators (3069)

•Non-Health Care Professionals (1452)

•Patients (357)

Setting of Care

•Hospitals (2455)

•Psychiatric Facilities (15)

•Residential Facilities (70)

•Ambulatory Care (382)

•Outpatient Surgery (42)

•Patient Transport (24)

1 - 20 of 3901

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COMMENTARY

Medication reconciliation in a community, nonteaching hospital.

Wortman SB. Am J Health Syst Pharm. 2008;65:2047-2054.

STUDY

Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.

Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25:441-447.

STUDY

Medication reconciliation: a qualitative analysis of clinicians' perceptions.

Vogelsmeier A, Pepper GA, Oderda L, Weir C. Res Social Adm Pharm. 2012 Oct 19; [Epub ahead of print].

COMMENTARY

An anesthesiology department leads culture change at a hospital system level to improve quality and patient safety.

Fleischut PM, Evans AS, Faggiani SL, Lazar EJ, Kerr GE. Anesthesiol Clin. 2011;29:153-167.

STUDY

Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge.

Ziaeian B, Araujo KLB, Van Ness PH, Horwitz LI. J Gen Intern Med. 2012;27:1513-1520.

STUDY

Effect of admission medication reconciliation on adverse drug events from admission medication changes.

Boockvar KS, Blum S, Kugler A, et al. Arch Intern Med. 2011;171:860-861.

STUDY

Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial.

Strom BL, Schinnar R, Aberra F, et al. Arch Intern Med. 2010;170:1578-1583.

COMMENTARY

Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council.

Fleischut PM, Evans AS, Nugent WC, et al. Am J Med Qual. 2011;26:89-94.

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

Effect of bar-code technology on the safety of medication administration.

Poon EG, Keohane CA, Yoon CS, et al. N Engl J Med. 2010;362:1698-1707.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.

STUDY

Effect of patient- and medication-related factors on inpatient medication reconciliation errors.

Salanitro AH, Osborn CY, Schnipper JL, et al. J Gen Intern Med. 2012;27:924-932.

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 on medication reconciliation on patient admission to a Veterans Affairs Medical Center.

Strunk LB, Matson AW, Steinke D. Hosp Pharm. 2008;43:643-649.

STUDY

Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study.

Paine LA, Rosenstein BJ, Sexton JB, Kent P, Holzmueller CG, Pronovost PJ. Qual Saf Health Care. 2010;19:547-554.

NEWSPAPER/MAGAZINE ARTICLE

Patients taking their own medications while in the hospital.

PA-PSRS Patient Saf Advis. June 2012;9:50-57.

STUDY

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network.

Poon EG, Blumenfeld B, Hamann C, et al. J Am Med Inform Assoc. 2006;13:581-592.

STUDY

Chronic kidney disease adversely influences patient safety.

Seliger SL, Zhan M, Hsu VD, Walker LD, Fink JC. J Am Soc Nephrol. 2008;19:2414-2419.

STUDY

Medication reconciliation: barriers and facilitators from the perspectives of resident physicians and pharmacists.

Boockvar KS, Santos SL, Kushniruk A, Johnson C, Nebeker JR. J Hosp Med. 2011;6:329-337.

COMMENTARY

Quality improvement through implementation of discharge order reconciliation.

Lu Y, Clifford P, Bjorneby A, et al. Am J Health Syst Pharm. 2013;70:815-820.

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