AHRQ Patient Safety Network

The Collection > Active Errors

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Safety Target

•Device-related Complications (64)

•Diagnostic Errors (187)

•Identification Errors (80)

•Discontinuities, Gaps, and Hand-Off Problems (146)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (445)

•Medical Complications (78)

•Nonsurgical Procedural Complications (37)

•Surgical Complications (155)

•Transfusion Complications (8)

•Psychological and Social Complications (44)

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•Africa (2)

•Asia (22)

•Australia and New Zealand (32)

•Central and South America (6)

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•Clinical Guideline (2)

•Journal Article (748)

•Legislation/Regulation (7)

•Meeting/Conference (4)

•Newspaper/Magazine Article (173)

•Press Release/Announcement (11)

•Special or Theme Issue (8)

•Tools/Toolkit (6)

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Error Types
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Active Errors

•Noncognitive Errors ("Slips & Lapses") (130)

•Cognitive Errors ("Mistakes") (179)

Approach to Improving Safety

•Quality Improvement Strategies (245)

•Legal and Policy Approaches (117)

•Error Reporting and Analysis (282)

•Communication Improvement (289)

•Human Factors Engineering (238)

•Teamwork (44)

•Specialization of Care (46)

•Logistical Approaches (66)

•Culture of Safety (73)

•Technologic Approaches (229)

•Education and Training (224)

Clinical Areas

•Allied Health Services (6)

•Medicine (788)

•Nursing (120)

•Pharmacy (156)

Target Audience

•Health Care Providers (797)

•Health Care Executives and Administrators (706)

•Non-Health Care Professionals (340)

•Patients (119)

Setting of Care

•Hospitals (682)

•Psychiatric Facilities (5)

•Residential Facilities (16)

•Ambulatory Care (134)

•Outpatient Surgery (17)

•Patient Transport (14)

1 - 20 of 1019

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NEWSPAPER/MAGAZINE ARTICLE

Medication errors occurring with the use of bar-code administration technology.

PA-PSRS Patient Saf Advis. December 2008;5:122-126.

STUDY

Association of interruptions with an increased risk and severity of medication administration errors.

Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Arch Intern Med. 2010;170:683-690.

STUDY

From the school of nursing quality and safety officer: nursing students' use of safety reporting tools and their perception of safety issues in clinical settings.

Cooper E. J Prof Nurs. 2013;29:109-116.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:696–698.

REVIEW

Bar code technology and medication administration error.

Young J, Slebodnik M, Sands L. J Patient Saf. 2010;6;115-120.

STUDY

Potential unintended consequences due to Medicare's "No Pay for Errors Rule"? A randomized controlled trial of an educational intervention with internal medicine residents.

Mookherjee S, Vidyarthi AR, Ranji SR, Maselli J, Wachter RM, Baron RB. J Gen Intern Med. 2010;25:1097-1101.

COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

COMMENTARY

Using simulation to teach nursing students and licensed clinicians obstetric emergencies.

Alderman JT. MCN Am J Matern Child Nurs. 2012;37:394-400.

STUDY

The application of Aronson's taxonomy to medication errors in nursing.

Johnson M, Young H. J Nurs Care Qual. 2011;26:128-135.

STUDY

Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study.

Mitchell EL, Lee DY, Arora S, et al. Acad Med. 2013 Apr 24; [Epub ahead of print].

STUDY

Effect of bar-code technology on the safety of medication administration.

Poon EG, Keohane CA, Yoon CS, et al. N Engl J Med. 2010;362:1698-1707.

TOOLS/TOOLKIT

Improving Transitions of Care: Hand-off Communications.

Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; June 2012.

STUDY

Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.

Kliger J, Blegen MA, Gootee D, O'Neil E. Jt Comm J Qual Patient Saf. 2009;35:604-612.

BOOK/REPORT classic

The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives.

Maxfield D, Grenny J, Lavandero R, Groah L. Provo, UT: VitalSmarts; 2011.

NEWSPAPER/MAGAZINE ARTICLE

Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.

ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.

STUDY

Questionable hospital chart documentation practices by physicians.

Sharma R, Kostis WJ, Wilson AC, et al. J Gen Intern Med. 2008;23:1865-1870.

STUDY

No interruptions please: impact of a no interruption zone on medication safety in intensive care units.

Anthony K, Wiencek C, Bauer C, Daly B, Anthony MK. Crit Care Nurse. 2010;30:21-29.

REVIEW

Hospital do-not-resuscitate orders: why they have failed and how to fix them.

Yuen JK, Reid MC, Fetters MD. J Gen Intern Med. 2011;26:791-797.

STUDY

Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.

Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25:441-447.

NEWSPAPER/MAGAZINE ARTICLE

Smart pump custom concentrations without hard "low concentration" alerts.

ISMP Medication Safety Alert! Acute Care Edition. February 23, 2012;17:1,3-4.

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