AHRQ Patient Safety Network

The Collection > United States of America

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Safety Target

•Device-related Complications (132)

•Diagnostic Errors (159)

•Identification Errors (92)

•Discontinuities, Gaps, and Hand-Off Problems (353)

•Fatigue and Sleep Deprivation (77)

•Medication Safety (1154)

•Medical Complications (343)

•Nonsurgical Procedural Complications (75)

•Surgical Complications (339)

•Transfusion Complications (15)

•Psychological and Social Complications (96)

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United States of America

•United States Federal Government (154)

•State Governments and Agencies (23)

Resource Types

•Audiovisual (32)

•Award (9)

•Book/Report (125)

•Clinical Guideline (7)

•Journal Article (2402)

•Legislation/Regulation (42)

•Meeting/Conference (15)

•Newsletter/Journal (7)

•Newspaper/Magazine Article (295)

•Press Release/Announcement (21)

•Special or Theme Issue (27)

•Tools/Toolkit (37)

•Web Resource (47)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (1041)

•Active Errors (458)

•Latent Errors (160)

•Near Miss (62)

Approach to Improving Safety

•Quality Improvement Strategies (695)

•Legal and Policy Approaches (244)

•Error Reporting and Analysis (1060)

•Communication Improvement (685)

•Human Factors Engineering (397)

•Teamwork (207)

•Specialization of Care (202)

•Logistical Approaches (252)

•Culture of Safety (324)

•Technologic Approaches (590)

•Education and Training (514)

Clinical Areas

•Allied Health Services (9)

Target Audience

•Health Care Providers (2156)

•Health Care Executives and Administrators (2566)

•Non-Health Care Professionals (1027)

•Patients (170)

Setting of Care

•Hospitals (1852)

•Psychiatric Facilities (14)

•Residential Facilities (100)

•Ambulatory Care (329)

•Outpatient Surgery (37)

•Patient Transport (22)

1 - 20 of 3068

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STUDY

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.

STUDY

Nursing home error and level of staff credentials.

Scott-Cawiezell J, Pepper GA, Madsen RW, Petroski G, Vogelsmeier A, Zellmer D. Clin Nurs Res. 2007;16:72-78.

STUDY

Adverse drug event reporting in intensive care units: a survey of current practices.

Kane-Gill SL, Devlin JW. Ann Pharmacother. 2006;40:1267-73.

STUDY

Evaluation of nationally mandated drug use reviews to improve patient safety in nursing homes: a natural experiment.

Briesacher B, Limcangco R, Simoni-Wastila L, Doshi J, Gurwitz J. J Am Geriatr Soc. 2005;53:991-996.

STUDY

Medication errors during patient transitions into nursing homes: characteristics and association with patient harm.

Desai R, Williams CE, Greene SB, Pierson S, Hansen RA. Am J Geriatr Pharmacother. 2011;9:413-422.

STUDY

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.

STUDY

Medication reconciliation for reducing drug-discrepancy adverse events.

Boockvar KS, Carlson Lacorte H, Giambanco V, Fridman B, Siu A. Am J Geriatr Pharmacother. 2006;4:236-243.

STUDY

The safety of warfarin therapy in the nursing home setting.

Gurwitz JH, Field TS, Radford MJ, et al. Am J Med. 2007;120:539-544.

STUDY

Nursing home administrators' opinions of the resident safety culture in nursing homes.

Castle NG, Handler S, Engberg J, Sonon K. Health Care Manage Rev. 2007;32:66-76.

STUDY

Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach.

Field TS, Tjia J, Mazor KM, et al. Am J Med. 2011;124:179.e1-179.e7.

STUDY

Assessment of adverse drug events among patients in a tertiary care medical center.

Johnston PE, France DJ, Byrne DW, et al. Am J Health Syst Pharm. 2006;63:2218-2227.

STUDY

Adverse drug events in the outpatient setting: an 11-year national analysis.

Bourgeois FT, Shannon MW, Valim C, Mandl KD. Pharmacoepidemiol Drug Saf. 2010;19:901-910.

STUDY

Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers.

Kachalia A, Gandhi TK, Puopolo AL, et al. Ann Emerg Med. Ann Emerg Med. 2007;49:196-205.

REVIEW

Computerized physician order entry with clinical decision support in long-term care facilities: costs and benefits to stakeholders.

Subramanian S, Hoover S, Gilman B, Field TS, Mutter R, Gurwitz JH. J Am Geriatr Soc. 2007;55:1451-1457.

STUDY

Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes.

Lapane KL, Hughes CM, Daiello LA, Cameron KA, Feinberg J. J Am Geriatr Soc. 2011;59:1238-1245.

STUDY

ARV medication errors: experience of a community-based HIV specialty clinic and review of the literature.

Cocohoba J, Dong BJ. Hosp Pharm. 2007;42:720-728.

STUDY

Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting.

Gurwitz JH, Field TS, Rochon P, et al. J Am Geriatr Soc. 2008;56:2225-2233.

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.

NEWSPAPER/MAGAZINE ARTICLE

Multiple latent failures align to allow a serious drug interaction to harm a patient.

ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.

STUDY

Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork.

Vogelsmeier A, Scott-Cawiezell J. J Nurs Care Qual. 2011;26:236-242.

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