AHRQ Patient Safety Network

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Identification Errors

•Wrong Patient (38)

•Wrong-Site Surgery (36)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (3)

Resource Types

•Journal Article (111)

•Legislation/Regulation (4)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (21)

•Special or Theme Issue (1)

•Tools/Toolkit (2)

•Web Resource (5)

Error Types

•Epidemiology of Errors and Adverse Events (56)

•Active Errors (65)

•Latent Errors (22)

•Near Miss (14)

Approach to Improving Safety

•Quality Improvement Strategies (51)

•Legal and Policy Approaches (11)

•Error Reporting and Analysis (55)

•Communication Improvement (56)

•Human Factors Engineering (43)

•Teamwork (12)

•Specialization of Care (2)

•Logistical Approaches (22)

•Culture of Safety (12)

•Technologic Approaches (52)

•Education and Training (24)

Clinical Areas

•Medicine (129)

•Nursing (11)

•Pharmacy (5)

Target Audience

•Health Care Providers (119)

•Health Care Executives and Administrators (132)

•Non-Health Care Professionals (48)

•Patients (20)

Setting of Care

•Hospitals (107)

•Psychiatric Facilities (1)

•Residential Facilities (2)

•Ambulatory Care (13)

•Outpatient Surgery (10)

1 - 20 of 160

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COMMENTARY

In Conversation with…Eric G. Poon, MD, MPH

AHRQ WebM&M [serial online]. September 2008.

NEWSPAPER/MAGAZINE ARTICLE

Wrist tag 'offers drug warning.'

BBC News. August 9, 2005.

STUDY

Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE).

Galanter W, Falck S, Burns M, Laragh M, Lambert BL. J Am Med Inform Assoc. 2013;20:477-481.

ORGANIZATIONAL POLICY/GUIDELINES

Standardising wristbands improves patient safety.

Safe Practice Notice 24. London, England: National Patient Safety Agency; July 3, 2007.

STUDY

Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.

Adelman JS, Kalkut GE, Schechter CB, et al. J Am Med Inform Assoc. 2013;20:305-310.

COMMENTARY

Patient Mix-Up.

Shojania KG. AHRQ WebM&M [serial online]. February 2003.

STUDY

Matching identifiers in electronic health records: implications for duplicate records and patient safety.

McCoy AB, Wright A, Kahn MG, Shapiro JS, Bernstam EV, Sittig DF. BMJ Qual Saf. 2013;22:219-224.

STUDY

The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.

Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. Qual Saf Health Care. 2010;19:430-434.

STUDY

Decreasing mislabeled laboratory specimens using barcode technology and bedside printers.

Brown JE, Smith N, Sherfy BR. J Nurs Care Qual. 2011;26:13-21.

STUDY

A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume endoscopy center.

Francis DL, Prabhakar S, Sanderson SO. Am J Gastroenterol. 2009;104:972-975.

NEWSPAPER/MAGAZINE ARTICLE

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.

COMMENTARY

Mistaken Identity

Hall LW. AHRQ WebM&M [serial online]. October 2008.

COMMENTARY classic

Computerization can create safety hazards: a bar-coding near miss.

McDonald CJ. Ann Intern Med. 2006;144:510-516.

STUDY

The use of patient pictures and verification screens to reduce computerized provider order entry errors.

Hyman D, Laire M, Redmond D, Kaplan DW. Pediatrics. 2012;130:e211-e219.

STUDY

Automated identification of extreme-risk events in clinical incident reports.

Ong MS, Magrabi F, Coiera E. J Am Med Inform Assoc. 2012;19:e110-e118.

BOOK/REPORT

Improving America's Hospitals: A Report on Quality and Safety.

Oakbrook Terrace, IL: The Joint Commission; March 2007.

STUDY

Patient safety in Taiwan: a survey on orthopedic surgeons.

Yang CT, Chen HH, Hou SM. J Formos Med Assoc. 2007;106:212-216.

STUDY

The nature and occurrence of registration errors in the emergency department.

Hakimzada AF, Green RA, Sayan OR, Zhang J, Patel VL. Int J Med Inform. 2008;77:169-175.

SPECIAL OR THEME ISSUE

SafetyNet: Lessons Learned from Close Calls in the OR.

AORN J. 2006;84(suppl 1):S1-S63.

STUDY

Specimen labeling errors in surgical pathology: an 18-month experience.

Layfield LJ, Anderson GM. Am J Clin Pathol. 2010;134:466-470.

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