AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (106)

•Diagnostic Errors (101)

•Identification Errors (45)

•Discontinuities, Gaps, and Hand-Off Problems (284)

•Fatigue and Sleep Deprivation (64)

•Medication Safety (1144)

•Medical Complications (298)

•Nonsurgical Procedural Complications (36)

•Surgical Complications (132)

•Transfusion Complications (14)

•Psychological and Social Complications (68)

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United States of America

•United States Federal Government (74)

•State Governments and Agencies (13)

Resource Types

•Audiovisual (53)

•Book/Report (119)

•Clinical Guideline (5)

•Journal Article (1614)

•Legislation/Regulation (30)

•Meeting/Conference (12)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (483)

•Press Release/Announcement (17)

•Special or Theme Issue (20)

•Tools/Toolkit (45)

•Web Resource (44)

Error Types

•Epidemiology of Errors and Adverse Events (559)

•Active Errors (419)

•Latent Errors (164)

•Near Miss (38)

Approach to Improving Safety

•Quality Improvement Strategies (594)

•Legal and Policy Approaches (292)

•Error Reporting and Analysis (718)

•Communication Improvement (542)

•Human Factors Engineering (291)

•Teamwork (108)

•Specialization of Care (220)

•Logistical Approaches (212)

•Culture of Safety (309)

•Technologic Approaches (532)

•Education and Training (436)

Clinical Areas

•Allied Health Services (4)

•Dentistry (1)

•Medicine (1507)

•Nursing (248)

•Pharmacy (564)

Target Audience

•Health Care Providers (1574)

•Health Care Executives and Administrators (1687)

•Non-Health Care Professionals (801)

•Patients (302)

Setting of Care

•Hospitals (1929)

•Psychiatric Facilities (10)

•Residential Facilities (43)

•Ambulatory Care (264)

•Outpatient Surgery (18)

•Patient Transport (8)

1 - 20 of 2464

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COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2007;42:884–888.

NEWSPAPER/MAGAZINE ARTICLE

Common cause analysis.

Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:618-621.

NEWSPAPER/MAGAZINE ARTICLE

Former pharmacist indicted for manslaughter after med error.

Paul R. Drug Topics. September 17, 2007;151:10.

STUDY

Rural inpatient telepharmacy consultation demonstration for after-hours medication review.

Cole SL, Grubbs JH, Din C, Nesbitt TS. Telemed E Health. 2012;18:530-537.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2007;42:1100-1102.

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

Impact of a pharmacotherapy alerting system on medication errors.

Natali BJ, Varkey AC, Garey KW, Liebl M. Am J Health Syst Pharm. 2013;70:48-52.

STUDY

classic

Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial.

Kripalani S, Roumie CL, Dalal AK, et al; PILL-CVD (Pharmacist Intervention for Low Literacy in Cardiovascular Disease) Study Group. Ann Intern Med. 2012;157:1-10.

BOOK/REPORT

Proceedings from the ISMP Sterile Preparation Compounding Safety Summit: Guidelines for SAFE Preparation of Sterile Compounds.

Horsham, PA: Institute for Safe Medication Practices; 2013.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2007;42:284–287.

REVIEW

"Tech-check-tech": a review of the evidence on its safety and benefits.

Adams AJ, Martin SJ, Stolpe SF. Am J Health Syst Pharm. 2011;68:1824-1833.

STUDY

ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2011.

Pedersen CA, Schneider PJ, Scheckelhoff DJ. Am J Health Syst Pharm. 2012;69:768-785.

NEWSPAPER/MAGAZINE ARTICLE

Rx for errors: speed, high volume can trigger mistakes.

McCoy K, Brady E. USA Today. February 11, 2008:A1.

NEWSPAPER/MAGAZINE ARTICLE

A shortage of everything except errors: harm associated with drug shortages.

ISMP Medication Safety Alert! Acute Care Edition. April 19, 2012;17:1-3.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2007;42:596-599.

NEWSPAPER/MAGAZINE ARTICLE

Misprogramming PCA concentration leads to dosing errors.

ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.

STUDY

Medication errors in a pharmacy-based bar-code-repackaging center.

Cina J, Fanikos J, Mitton P, McCrea M, Churchill W. Am J Health Syst Pharm. 2006;63:165-168.

COMMENTARY

Current status of the monitoring of medication practice.

Cousins D. Am J Health Syst Pharm. 2009;66:S49-S56.

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