AHRQ Patient Safety Network

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•Device-related Complications (25)

•Diagnostic Errors (3)

•Identification Errors (5)

•Discontinuities, Gaps, and Hand-Off Problems (54)

•Medication Safety (620)

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Error Types

•Epidemiology of Errors and Adverse Events (173)

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Approach to Improving Safety

•Quality Improvement Strategies (140)

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Pharmacy

•Hospital Pharmacy (221)

•Community Pharmacy (48)

Target Audience

•Health Care Providers (548)

•Health Care Executives and Administrators (415)

•Non-Health Care Professionals (178)

•Patients (75)

Setting of Care

•Hospitals (295)

•Psychiatric Facilities (2)

•Residential Facilities (14)

•Ambulatory Care (112)

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1 - 20 of 639

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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.

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.

COMMENTARY

ISMP medication error report analysis.

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

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.

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.

STUDY

Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.

Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.

STUDY

Adverse drug events in the outpatient setting: an 11-year national analysis.

Bourgeois FT, Shannon MW, Valim C, Mandl KD. Pharmacoepidemiol Drug Saf. 2010;19:901-910.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:643-648.

NEWSPAPER/MAGAZINE ARTICLE

Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups?

ISMP Medication Safety Alert! Acute Care Edition. May 21, 2009;14:1-3.

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.

NEWSPAPER/MAGAZINE ARTICLE

Generic drug names: fertile ground for errors?

Wynn P. Drug Topics Supplements. August 8, 2005.

REVIEW

Year in review: medication mishaps in the elderly.

Peron EP, Marcum ZA, Boyce R, Hanlon JT, Handler SM. Am J Geriatr Pharmacother. 2011;9:1-10.

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