AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (128)

•Diagnostic Errors (147)

•Identification Errors (87)

•Discontinuities, Gaps, and Hand-Off Problems (663)

•Fatigue and Sleep Deprivation (90)

•Medication Safety (1283)

•Medical Complications (397)

•Nonsurgical Procedural Complications (40)

•Surgical Complications (247)

•Transfusion Complications (16)

•Psychological and Social Complications (99)

Origin/Sponsor

•Africa (5)

•Asia (34)

•Australia and New Zealand (68)

•Central and South America (3)

•Europe (324)

•North America (2639)

Resource Types

•Audiovisual (39)

•Award (9)

•Book/Report (147)

•Clinical Guideline (3)

•Journal Article (2372)

•Legislation/Regulation (26)

•Meeting/Conference (9)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (356)

•Press Release/Announcement (6)

•Special or Theme Issue (25)

•Tools/Toolkit (41)

•Web Resource (45)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (1305)

•Active Errors (446)

•Latent Errors (183)

•Near Miss (59)

Approach to Improving Safety

•Quality Improvement Strategies (673)

•Legal and Policy Approaches (268)

•Error Reporting and Analysis (951)

•Communication Improvement (833)

•Human Factors Engineering (323)

•Teamwork (170)

•Specialization of Care (245)

•Logistical Approaches (274)

•Culture of Safety (348)

•Technologic Approaches (613)

•Education and Training (516)

Clinical Areas

•Allied Health Services (7)

•Medicine (2460)

•Nursing (247)

•Pharmacy (486)

Target Audience

•Health Care Providers (1966)

•Health Care Executives and Administrators (2300)

•Non-Health Care Professionals (1006)

•Patients (246)

Setting of Care

•Hospitals (2326)

•Psychiatric Facilities (12)

•Residential Facilities (58)

•Ambulatory Care (358)

•Outpatient Surgery (24)

•Patient Transport (25)

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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

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

Medication details documented on hospital discharge: cross-sectional observational study of factors associated with medication non-reconciliation.

Grimes TC, Duggan CA, Delaney TP, et al. Br J Clin Pharmacol. 2011;71:449-457.

STUDY

Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.

Schillig J, Kaatz S, Hudson M, Krol GD, Szandzik EG, Kalus JS. J Hosp Med. 2011;6:322-328.

STUDY

Nurse–pharmacist collaboration on medication reconciliation prevents potential harm.

Feldman LS, Costa LL, Feroli ER Jr, et al. J Hosp Med. 2012;7:396-401.

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

Discrepancies between home medications listed at hospital admission and reported medical conditions.

Slain D, Kincaid SE, Dunsworth TS. Am J Geriatr Pharmacother. 2008;6:161-166.

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

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

Patient risk factors for medical injury: a case–control study.

Marbella AM, Laud PW, Brasel KJ, Layde PM. BMJ Qual Saf. 2011;20:187-193.

COMMENTARY

Implementing online medication reconciliation at a large academic medical center.

Bails D, Clayton K, Roy K, Cantor MN. Jt Comm J Qual Patient Saf. 2008;34:499-508.

STUDY

Physician reporting of clinically significant events through a computerized patient sign-out system.

Nabors C, Peterson SJ, Aronow WS, et al. J Patient Saf. 2011;7:154-160.

STUDY

Improving the discharge process by embedding a discharge facilitator in a resident team.

Finn KM, Heffner R, Chang Y, et al. J Hosp Med. 2011;6:494-500.

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 an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial.

Schnipper JL, Hamann C, Ndumele CD, et al. Arch Intern Med. 2009;169:771-780.

NEWSPAPER/MAGAZINE ARTICLE

Survey results: community liaison programs to decrease hospital readmissions.

ISMP Medication Safey Alert! Acute Care Edition. March 7, 2013;18:1-3.

REVIEW

Hospital-based medication reconciliation practices: a systematic review.

Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Arch Intern Med. 2012;172:1057-1069.

COMMENTARY

Medication reconciliation in a community, nonteaching hospital.

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

NEWSPAPER/MAGAZINE ARTICLE

Following the patient journey to improve medicines management and reduce errors.

Crocker C. Nurs Times. 2009 Nov 24;105:12-15.

STUDY

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.

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