AHRQ Patient Safety Network

The Collection > Active Errors

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Safety Target

•Device-related Complications (58)

•Diagnostic Errors (105)

•Identification Errors (63)

•Discontinuities, Gaps, and Hand-Off Problems (89)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (313)

•Medical Complications (70)

•Nonsurgical Procedural Complications (29)

•Surgical Complications (119)

•Transfusion Complications (5)

•Psychological and Social Complications (36)

Origin/Sponsor

•Africa (1)

•Asia (7)

•Australia and New Zealand (13)

Resource Types

•Clinical Guideline (2)

•Journal Article (466)

•Legislation/Regulation (5)

•Meeting/Conference (1)

•Newspaper/Magazine Article (172)

•Press Release/Announcement (7)

•Special or Theme Issue (5)

•Tools/Toolkit (6)

•Web Resource (10)

•Grant (1)

Error Types
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Active Errors

•Noncognitive Errors ("Slips & Lapses") (56)

•Cognitive Errors ("Mistakes") (89)

Approach to Improving Safety

•Quality Improvement Strategies (178)

•Legal and Policy Approaches (113)

•Error Reporting and Analysis (216)

•Communication Improvement (216)

•Human Factors Engineering (157)

•Teamwork (26)

•Specialization of Care (28)

•Logistical Approaches (44)

•Culture of Safety (61)

•Technologic Approaches (158)

•Education and Training (142)

Clinical Areas

•Allied Health Services (7)

Target Audience

•Health Care Providers (532)

•Health Care Executives and Administrators (484)

•Non-Health Care Professionals (217)

•Patients (137)

Setting of Care

•Hospitals (495)

•Psychiatric Facilities (3)

•Residential Facilities (11)

•Ambulatory Care (99)

•Outpatient Surgery (14)

•Patient Transport (9)

1 - 20 of 727

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AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.

NEWSPAPER/MAGAZINE ARTICLE

Why don't doctors wash their hands more?

Chen PW. New York Times. September 17, 2009.

NEWSPAPER/MAGAZINE ARTICLE

U.S. inaction lets look-alike tubes kill patients.

Harris G. New York Times. August 21, 2010:A1.

COMMENTARY

As she lay dying: how I fought to stop medical errors from killing my mom.

Welch JR. Health Aff (Millwood). 2012;31:2817-2820.

COMMENTARY

Staggered Sensitivity Results

Guglielmo BJ. AHRQ WebM&M [serial online]. March 2007.

COMMENTARY

In Conversation with...Steven J. Spear, DBA, MS, MS

AHRQ WebM&M [serial online]. August 2009.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals tally their avoidable mistakes.

Rein L. Washington Post. July 21, 2009:E1.

REVIEW

Negligence, genuine error, and litigation.

Sohn DH. Int J Gen Med. 2013;6:49-56.

COMMENTARY

Making Just Culture a Reality: One Organization's Approach

Page AH. AHRQ WebM&M [serial online]. October 2007.

STUDY

Relationship between systems-level factors and hand hygiene adherence.

Dunn-Navarra AM, Cohen B, Stone PW, Pogorzelska M, Jordan S, Larson E. J Nurs Care Qual. 2011;26:30-38.

COMMENTARY classic

Balancing "no blame" with accountability in patient safety.

Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.

NEWSPAPER/MAGAZINE ARTICLE

Brigham and Women's airing medical mistakes.

Kowalczyk L. Boston Globe. April 9, 2013.

NEWSPAPER/MAGAZINE ARTICLE

Medical errors harm huge number of patients. What will it take to make America's hospitals safer?

Sternberg S. US News & World Report. August 28, 2012.

NEWSPAPER/MAGAZINE ARTICLE

Shared MDIs: can cross-contamination be avoided?

ISMP Medication Safety Alert! Acute Care Edition. April 9, 2009;14:1-3.

BOOK/REPORT classic

When Things Go Wrong: Responding to Adverse Events.

A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.

STUDY

Injection practices among clinicians in United States health care settings.

Pugliese G, Gosnell C, Bartley JM, Robinson S. Am J Infect Control. 2010;38:789-798.

NEWSPAPER/MAGAZINE ARTICLE

Inquiry into reporter's death finds multiple failures in care.

Stout D. New York Times. June 17, 2006;National desk:9.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2012.

NEWSPAPER/MAGAZINE ARTICLE

Don't let a hospital make you sick.

Mishori R. Parade Magazine. February 8, 2009.

COMMENTARY

Learning accountability for patient outcomes.

Pronovost PJ. JAMA. 2010;304:204-205.

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