AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (156)

•Diagnostic Errors (196)

•Identification Errors (101)

•Discontinuities, Gaps, and Hand-Off Problems (387)

•Fatigue and Sleep Deprivation (92)

•Medication Safety (1269)

•Medical Complications (364)

•Nonsurgical Procedural Complications (103)

•Surgical Complications (421)

•Transfusion Complications (16)

•Psychological and Social Complications (111)

Origin/Sponsor

•Africa (3)

•Asia (40)

•Australia and New Zealand (84)

•Central and South America (7)

•Europe (332)

•North America (2999)

Resource Types

•Clinical Guideline (6)

•Journal Article (2570)

•Legislation/Regulation (59)

•Meeting/Conference (30)

•Newsletter/Journal (12)

•Newspaper/Magazine Article (334)

•Press Release/Announcement (49)

•Special or Theme Issue (56)

•Tools/Toolkit (54)

•Web Resource (103)

•Grant (8)

Error Types

•Epidemiology of Errors and Adverse Events (810)

•Active Errors (708)

•Latent Errors (239)

•Near Miss (80)

Approach to Improving Safety

•Quality Improvement Strategies (847)

•Legal and Policy Approaches (317)

•Error Reporting and Analysis (993)

•Communication Improvement (925)

•Human Factors Engineering (514)

•Teamwork (287)

•Specialization of Care (234)

•Logistical Approaches (243)

•Culture of Safety (411)

•Technologic Approaches (631)

•Education and Training (678)

Clinical Areas

•Allied Health Services (16)

•Complementary and Alternative Medicine (2)

Target Audience
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Health Care Providers

•Allied Health Professionals (6)

•Clinical Technologists (31)

Setting of Care

•Psychiatric Facilities (17)

•Residential Facilities (67)

•Ambulatory Care (373)

•Outpatient Surgery (40)

•Patient Transport (30)

1 - 20 of 3534

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STUDY

Listen carefully: the risk of error in spoken medication orders.

Lambert BL, Dickey LW, Fisher WM, et al. Soc Sci Med. 2010;70:1599-1608.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:282-287.

COMMENTARY

ISMP medication error report analysis.

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

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:288-292.

COMMENTARY

Medication errors related to product names.

Santell JP, Cousins DD. Jt Comm J Qual Patient Saf. 2005;31:649-654.

COMMENTARY

Dealing honestly with an honest mistake.

Liang NL, Herring ME, Bush RL. J Vasc Surg. 2010;51:494-495.

PRESS RELEASE/ANNOUNCEMENT

Medication errors resulting from confusion between risperidone (Risperdal) and ropinirole (Requip).

MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; June 13, 2011.

STUDY

A comparison of voluntarily reported medication errors in intensive care and general care units.

Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:937-938, 945.

STUDY

Wrong-site craniotomy: analysis of 35 cases and systems for prevention.

Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473.

STUDY

Origins of and solutions for neonatal medication-dispensing errors.

Sauberan JB, Dean LM, Fiedelak J, Abraham JA. Am J Health Syst Pharm. 2010;67:49-57.

STUDY

Identifying and reducing medication errors in psychiatry: creating a culture of safety through the use of an adverse event reporting mechanism.

Jayaram G, Doyle D, Steinwachs D, Samuels J. J Psychiatr Pract. 2011;17:81–88.

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.

NEWSPAPER/MAGAZINE ARTICLE

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Preventing catheter/tubing misconnections: much needed help is on the way.

ISMP Medication Safety Alert! Acute Care Edition. July 15, 2010;15:1-2.

COMMENTARY

Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine?

Reddy GK, Brown B, Nanda A. Clin Neurol Neurosurg. 2011;113:68-71.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:18-21.

NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

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

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:405-406.

STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

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