AHRQ Patient Safety Network

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Identification Errors

•Wrong Patient (47)

•Wrong-Site Surgery (59)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (4)

Resource Types

•Clinical Guideline (1)

•Journal Article (107)

•Legislation/Regulation (5)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (39)

•Special or Theme Issue (2)

•Tools/Toolkit (3)

•Web Resource (8)

Error Types

•Epidemiology of Errors and Adverse Events (60)

•Active Errors (78)

•Latent Errors (24)

•Near Miss (14)

Approach to Improving Safety

•Quality Improvement Strategies (60)

•Legal and Policy Approaches (17)

•Error Reporting and Analysis (61)

•Communication Improvement (81)

•Human Factors Engineering (53)

•Teamwork (19)

•Specialization of Care (3)

•Logistical Approaches (20)

•Culture of Safety (19)

•Technologic Approaches (45)

•Education and Training (31)

Clinical Areas

Target Audience

•Health Care Providers (131)

•Health Care Executives and Administrators (138)

•Non-Health Care Professionals (47)

•Patients (37)

Setting of Care

•Hospitals (131)

•Psychiatric Facilities (1)

•Residential Facilities (1)

•Ambulatory Care (15)

•Outpatient Surgery (10)

1 - 20 of 182

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MULTI-USE WEBSITE

Standardization Projects.

Washington State Hospital Association.

BOOK/REPORT

Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-08-00220.

COMMENTARY

Check the Wristband.

Rosenthal MM. AHRQ WebM&M [serial online]. July 2003.

BOOK/REPORT

Meeting the Joint Commission's 2013 National Patient Safety Goals.

Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.

NEWSPAPER/MAGAZINE ARTICLE

Empowered to improve.

Gardner E. Mod Healthc. May 18, 2009;39:28-31.

NEWSPAPER/MAGAZINE ARTICLE

Get me out alive.

Feldman R. The Washington Post. May 2, 2006:HE01.

BOOK/REPORT

Consumer Guide to Adverse Health Events.

St. Paul, MN: Minnesota Department of Health; January 2009.

NEWSPAPER/MAGAZINE ARTICLE

10 things your hospital won't tell you.

Kapadia R. Smart Money. October 2006;15:112-114.

BOOK/REPORT

Adverse Health Events in Minnesota: Ninth Annual Public Report.

St. Paul, MN: Minnesota Department of Health; January 2013.

STUDY

Error tracking in a clinical biochemistry laboratory.

Szecsi PB, Ødum L. Clin Chem Lab Med. 2009;47:1253-1257.

STUDY

Incident reporting practices in the preanalytical phase: low reported frequencies in the primary health care setting.

Söderberg J, Grankvist K, Brulin C, Wallin O. Scand J Clin Lab Invest. 2009;69:731-735.

FACT SHEET/FAQS

Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.

Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Never events: Utah hospitals saw nearly 60 serious errors in 2007.

May H. Salt Lake Tribune. August 18, 2008.

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.

STUDY

Reduction in pediatric identification band errors: a quality collaborative.

Phillips SC, Saysana M, Worley S, Hain PD. Pediatrics. 2012;129:e1587-e1593.

NEWSPAPER/MAGAZINE ARTICLE

The wrong foot, and other tales of surgical error.

Altman LK. New York Times. December 11, 2001;1:1.

STUDY

Preanalytical errors in primary healthcare: a questionnaire study of information search procedures, test request management and test tube labelling.

Söderberg J, Brulin C, Grankvist K, Wallin O. Clin Chem Lab Med. 2009;47:195-201.

COMMENTARY classic

Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand.

Ring DC, Herndon JH, Meyer GS. N Engl J Med. 2010;363:1950-1957.

STUDY

He thought the "lady in the door" was the "lady in the window": a qualitative study of patient identification practices.

Phipps E, Turkel M, Mackenzie ER, Urrea C. Jt Comm J Qual Patient Saf. 2012;38:127-134.

COMMENTARY

2009 National Patient Safety Goals.

Saufl NM. J Perianesth Nurs. 2009;24:114-118.

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