AHRQ Patient Safety Network

The Collection > Active Errors

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Safety Target

•Device-related Complications (46)

•Diagnostic Errors (113)

•Identification Errors (58)

•Discontinuities, Gaps, and Hand-Off Problems (133)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (315)

•Medical Complications (66)

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Active Errors

•Noncognitive Errors ("Slips & Lapses") (78)

•Cognitive Errors ("Mistakes") (66)

Approach to Improving Safety

•Quality Improvement Strategies (184)

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•Allied Health Services (3)

•Medicine (537)

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Target Audience

•Health Care Providers (586)

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Setting of Care

•Hospitals (484)

•Psychiatric Facilities (5)

•Residential Facilities (13)

•Ambulatory Care (109)

•Outpatient Surgery (13)

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1 - 20 of 669

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NEWSPAPER/MAGAZINE ARTICLE

Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.

ISMP Medication Safety Alert! Acute Care Edition. August 26, 2010;15:1-3.

STUDY

Discontinuation of antihyperglycemic therapy after acute myocardial infarction: medical necessity or medical error?

Lovig KO, Horwitz L, Lipska K, Kosiborod M, Krumholz HM, Inzucchi SE. Jt Comm J Qual Patient Saf. 2012;38:403-407.

COMMENTARY

Medication Reconciliation Victory after an Avoidable Error

Cutler TW. AHRQ WebM&M [serial online]. February/March 2009.

STUDY

Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model.

White RE, Trbovich PL, Easty AC, Savage P, Trip K, Hyland S. Qual Saf Health Care. 2010;19:562-567.

BOOK/REPORT

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.

Toft B. London, England: Department of Health; 2001.

REVIEW

Medication errors in chemotherapy: incidence, types and involvement of patients in prevention. A review of the literature.

Schwappach DLB, Wernli M. Eur J Cancer Care (Engl). 2009;19:285-292.

COMMENTARY

Recurrent Hypoglycemia: A Care Transition Failure?

Eytan T. AHRQ WebM&M [serial online]. October 2008.

STUDY

Medication discrepancies upon hospital to skilled nursing facility transitions.

Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. J Gen Intern Med. 2009;24:630-635.

COMMENTARY

Language Barrier

Flores G. AHRQ WebM&M [serial online]. April 2006.

COMMENTARY

Patient Safety: A Perspective from Office Practice.

Baron RJ. AHRQ WebM&M [serial online]. May 2009.

STUDY

Interruptions during the delivery of high-risk medications.

Trbovich P, Prakash V, Stewart J, Trip K, Savage P. J Nurs Adm. 2010;40:211-218.

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].

COMMENTARY

Improving care transitions: current practice and future opportunities for pharmacists.

American College of Clinical Pharmacy, Hume AL, Kirwin J, et al. Pharmacotherapy. 2012;32:e326-e337.

TOOLS/TOOLKIT

Improving Transitions of Care: Hand-off Communications.

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

STUDY

Pediatric antidepressant medication errors in a national error reporting database.

Rinke ML, Bundy DG, Shore AD, Colantuoni E, Morlock LL, Miller MR. J Dev Behav Pediatr. 2010;31:129-136.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2013.

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.

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.

STUDY

Handoff communication between hospital and outpatient dialysis units at patient discharge: a qualitative study.

Reilly JB, Marcotte LM, Berns JS, Shea JA. Jt Comm J Qual Patient Saf. 2013;39:70-76.

STUDY

Errors of diagnosis in pediatric practice: a multisite survey.

Singh H, Thomas EJ, Wilson L, et al. Pediatrics. 2010;126:70-79.

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