AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (49)

•Diagnostic Errors (66)

•Identification Errors (33)

•Discontinuities, Gaps, and Hand-Off Problems (82)

•Fatigue and Sleep Deprivation (43)

•Medication Safety (243)

•Medical Complications (58)

•Nonsurgical Procedural Complications (31)

•Surgical Complications (122)

•Transfusion Complications (5)

•Psychological and Social Complications (26)

Origin/Sponsor

•Asia (20)

•Australia and New Zealand (22)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (671)

•Legislation/Regulation (9)

•Meeting/Conference (2)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (68)

•Press Release/Announcement (17)

•Special or Theme Issue (7)

•Tools/Toolkit (6)

•Web Resource (7)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (269)

•Active Errors (148)

•Latent Errors (51)

•Near Miss (24)

Approach to Improving Safety

•Quality Improvement Strategies (189)

•Legal and Policy Approaches (105)

•Error Reporting and Analysis (367)

•Communication Improvement (156)

•Human Factors Engineering (121)

•Teamwork (40)

•Specialization of Care (32)

•Logistical Approaches (71)

•Culture of Safety (64)

•Technologic Approaches (117)

•Education and Training (94)

Clinical Areas

•Allied Health Services (3)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (444)

•Psychiatric Facilities (3)

•Residential Facilities (12)

•Ambulatory Care (53)

•Outpatient Surgery (12)

•Patient Transport (9)

1 - 20 of 831

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STUDY

Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center.

McCullough J, McKenna D, Kadidlo D, et al. Blood. 2009:114:1684-1688.

NEWSPAPER/MAGAZINE ARTICLE

Lost surgical specimens, lost opportunities.

PA-PSRS Patient Saf Advis. September 2005;2:1-5.

STUDY

Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety.

Collins CM, Elsaid KA. Int J Qual Health Care. 2011;23:36-43.

STUDY

The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer.

Raab SS, Meier FA, Zarbo RJ, et al. J Clin Oncol. 2006;24:2808-2814.

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.

STUDY

Has the pendulum swung too far? The impact of missed abdominal injuries in the era of nonoperative management.

Fairfax LM, Christmas AB, DeAugustinis M, et al. Am Surg. 2009;75:558-564.

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

Outside case review of surgical pathology for referred patients: the impact on patient care.

Swapp RE, Aubry MC, Salomão DR, Cheville JC. Arch Pathol Lab Med. 2013;137:233-240.

STUDY

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

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

STUDY

Revisiting old slides—how worthwhile is it?

Agarwal S, Wadhwa N. Pathol Res Pract. 2010;206:368-371.

STUDY

Gossypiboma: tales of lost sponges and lessons learned.

McIntyre LK, Jurkovich GJ, Gunn MLD, Maier RV. Arch Surg. 2010;145:770-775.

STUDY

Ambulance personnel perceptions of near misses and adverse events in pediatric patients.

Cushman JT, Fairbanks RJ, O'Gara KG, et al. Prehosp Emerg Care. 2010;14:477-484.

STUDY

Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after 1,946,831 operations in children.

Camp M, Chang DC, Zhang Y, Chrouser K, Colombani PM, Abdullah F. Arch Surg. 2010;145:1085-1090.

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.

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.

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.

STUDY

Comparison of the clinical diagnosis and subsequent autopsy findings in medical malpractice.

Pakis I, Polat O, Yayci N, Karapirli M. Am J Forensic Med Pathol. 2010;31:218-221.

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

What pilots can teach hospitals about patient safety.

Murphy K. New York Times. October 31, 2006:F5.

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.

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