AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (164)

•Diagnostic Errors (144)

•Identification Errors (107)

•Discontinuities, Gaps, and Hand-Off Problems (463)

•Fatigue and Sleep Deprivation (97)

•Medication Safety (989)

•Medical Complications (503)

•Nonsurgical Procedural Complications (99)

•Surgical Complications (492)

•Transfusion Complications (21)

•Psychological and Social Complications (115)

Origin/Sponsor

•Africa (3)

•Asia (54)

•Australia and New Zealand (99)

•Central and South America (9)

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•North America (2849)

Resource Types

•Audiovisual (36)

•Award (21)

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•Newspaper/Magazine Article (460)

•Press Release/Announcement (11)

•Special or Theme Issue (34)

•Tools/Toolkit (42)

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Error Types

•Epidemiology of Errors and Adverse Events (930)

•Active Errors (625)

•Latent Errors (260)

•Near Miss (63)

Approach to Improving Safety

•Quality Improvement Strategies (856)

•Legal and Policy Approaches (329)

•Error Reporting and Analysis (1043)

•Communication Improvement (840)

•Human Factors Engineering (484)

•Teamwork (302)

•Specialization of Care (316)

•Logistical Approaches (303)

•Culture of Safety (467)

•Technologic Approaches (631)

•Education and Training (669)

Clinical Areas

•Allied Health Services (3)

•Medicine (2636)

•Nursing (343)

•Pharmacy (363)

Target Audience

•Health Care Providers (2414)

•Health Care Executives and Administrators (2790)

•Non-Health Care Professionals (1199)

•Patients (321)

Setting of Care
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Hospitals

•General Hospitals (1148)

•Children’s Hospitals (120)

•Specialty Hospitals (72)

1 - 20 of 3481

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NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

ISMP Medication Safety Alert! Acute Care Edition. May 3, 2007;12:1-2.

STUDY

Diagnostic errors with inserted tubes, lines and catheters in children.

Fuentealba I, Taylor GA. Pediatr Radiol. 2012;42:1305-1315.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:1062-1065.

STUDY

Paid malpractice claims for adverse events in inpatient and outpatient settings.

Bishop TF, Ryan AK, Casalino LP. JAMA. 2011;305:2427-2431.

NEWSPAPER/MAGAZINE ARTICLE

Shared MDIs: can cross-contamination be avoided?

ISMP Medication Safety Alert! Acute Care Edition. April 9, 2009;14:1-3.

MEASUREMENT TOOL/INDICATOR

Tubing Misconnections Self Assessment for Healthcare Facilities.

Horsham, PA: Institute for Safe Medication Practices, Deerfield, IL: Baxter Healthcare; 2012.

STUDY

Eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particular emphasis on CT.

McCreadie G, Oliver TB. Clin Radiol. 2009;64:491-499; discussion 500-501.

STUDY

Accuracy of radiographic readings in the emergency department.

Petinaux B, Bhat R, Boniface K, Aristizabal J. Am J Emerg Med. 2011;29:18-25.

STUDY

The computerized rounding report: implementation of a model system to support transitions of care.

Wohlauer MV, Rove KO, Pshak TJ, et al. J Surg Res. 2012;172:11-17.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:696–698.

STUDY

Handoff communication between hospital and outpatient dialysis units at patient discharge: a qualitative study.

Reilly JB, Marcotte LM, Berns JS, Shea JA. Jt Comm J Qual Patient Saf. 2013;39:70-76.

STUDY

Cardiovascular medication errors in children.

Alexander DC, Bundy DG, Shore AD, Morlock L, Hicks RW, Miller MR. Pediatrics. 2009;124:324-332.

NEWSPAPER/MAGAZINE ARTICLE

Spike in MR imaging accidents underscores need for regulation.

Radiological Society of North America. RSNA News; October 2010.

STUDY

Improving the usability of intravenous medication labels to support safe medication delivery.

Bauer DT, Guerlain S. Int J Ind Ergon. 2011;41:394-399.

COMMENTARY

Is the Admission Drug Dose Too Low?

Kaushal R, Abramson E. AHRQ WebM&M [serial online]. August 2009.

ORGANIZATIONAL POLICY/GUIDELINES

Medical device alarm safety in hospitals.

Sentinel Event Alert. April 8, 2013;(50):1-3.

STUDY

The frequency of diagnostic errors in radiologic reports depends on the patient's age.

Diaz S, Ekberg O. Acta Radiol. 2010;51:934-938.

STUDY

Pediatric antidepressant medication errors in a national error reporting database.

Rinke ML, Bundy DG, Shore AD, Colantuoni E, Morlock LL, Miller MR. J Dev Behav Pediatr. 2010;31:129-136.

STUDY

Venous thromboembolism after trauma: a never event?

Thorson CM, Ryan ML, Van Haren RM, et al. Crit Care Med. 2012;40:2967-2973.

STUDY

Wisdom through adversity: learning and growing in the wake of an error.

Plews-Ogan M, Owens JE, May NB. Patient Educ Couns. 2013;91:236-242.

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