AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (48)

•Diagnostic Errors (63)

•Identification Errors (31)

•Discontinuities, Gaps, and Hand-Off Problems (83)

•Fatigue and Sleep Deprivation (42)

•Medication Safety (256)

•Medical Complications (61)

•Nonsurgical Procedural Complications (31)

•Surgical Complications (120)

•Transfusion Complications (5)

•Psychological and Social Complications (27)

Origin/Sponsor

•Asia (19)

•Australia and New Zealand (24)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (675)

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•Newspaper/Magazine Article (69)

•Press Release/Announcement (17)

•Special or Theme Issue (8)

•Tools/Toolkit (6)

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Error Types

•Epidemiology of Errors and Adverse Events (276)

•Active Errors (154)

•Latent Errors (50)

•Near Miss (26)

Approach to Improving Safety

•Quality Improvement Strategies (185)

•Legal and Policy Approaches (100)

•Error Reporting and Analysis (371)

•Communication Improvement (157)

•Human Factors Engineering (120)

•Teamwork (42)

•Specialization of Care (32)

•Logistical Approaches (67)

•Culture of Safety (63)

•Technologic Approaches (120)

•Education and Training (94)

Clinical Areas

•Allied Health Services (3)

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Risk Managers

Setting of Care

•Hospitals (447)

•Psychiatric Facilities (4)

•Residential Facilities (11)

•Ambulatory Care (55)

•Outpatient Surgery (11)

•Patient Transport (9)

1 - 20 of 836

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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. 2009;44:288-292.

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

Dealing honestly with an honest mistake.

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

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.

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

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

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

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

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

STUDY

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

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

NEWSPAPER/MAGAZINE ARTICLE

Fatal outcome after inadvertent injection of topical epinephrine.

ISMP Medication Safety Alert! Acute Care Edition. March 26, 2009;14:1-2.

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.

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.

COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

NEWSPAPER/MAGAZINE ARTICLE

Promethazine conundrum: IV can hurt more than IM injection!

ISMP Medication Safety Alert! Acute Care Edition. November 2, 2006;11:1-3.

STUDY

Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.

Lin MY, Hota B, Khan YM, et al; CDC Prevention Epicenter Program. JAMA. 2010;304:2035-2041.

COMMENTARY

Miscalculated Risk

Strassels SA. AHRQ WebM&M [serial online]. August 2006.

STUDY

Inaccuracy of ECG interpretations reported to the poison center.

Prosser JM, Smith SW, Rhim ES, Olsen D, Nelson LS, Hoffman RS. Ann Emerg Med. 2011;57:122-127.

NEWSPAPER/MAGAZINE ARTICLE

An overlooked condition.

Nicholas L. Modern Healthc. November 14, 2005;35:24.

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