AHRQ Patient Safety Network

The Collection > Active Errors

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Safety Target

•Device-related Complications (46)

•Diagnostic Errors (72)

•Identification Errors (56)

•Discontinuities, Gaps, and Hand-Off Problems (66)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (325)

•Medical Complications (50)

•Nonsurgical Procedural Complications (23)

•Surgical Complications (113)

•Transfusion Complications (3)

•Psychological and Social Complications (25)

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•Asia (2)

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•Central and South America (1)

Resource Types

•Clinical Guideline (2)

•Journal Article (397)

•Legislation/Regulation (5)

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•Newspaper/Magazine Article (164)

•Press Release/Announcement (7)

•Special or Theme Issue (3)

•Tools/Toolkit (7)

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Error Types
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Active Errors

•Noncognitive Errors ("Slips & Lapses") (19)

•Cognitive Errors ("Mistakes") (70)

Approach to Improving Safety

•Quality Improvement Strategies (130)

•Legal and Policy Approaches (97)

•Error Reporting and Analysis (172)

•Communication Improvement (178)

•Human Factors Engineering (172)

•Teamwork (25)

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•Logistical Approaches (33)

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•Technologic Approaches (135)

•Education and Training (115)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (471)

•Health Care Executives and Administrators (428)

•Non-Health Care Professionals (177)

•Patients (132)

Setting of Care

•Hospitals (404)

•Psychiatric Facilities (1)

•Residential Facilities (10)

•Ambulatory Care (99)

•Outpatient Surgery (12)

•Patient Transport (10)

1 - 20 of 638

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STUDY

Out-of-hospital medication errors: a 6-year analysis of the national poison data system.

Shah K, Barker KA. Pharmacoepidemiol Drug Saf. 2009;18:1080-1085.

COMMENTARY

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.

AUDIOVISUAL

Pharmacy mixes up prescriptions.

Haythorn R. ABC News. February 7, 2011.

NEWSPAPER/MAGAZINE ARTICLE

Pharmacy reform reduces Rx errors: '05 CVS mishap spurred action.

Fargen J. Boston Herald. April 22, 2007.

NEWSPAPER/MAGAZINE ARTICLE

Medication mistakes that can kill.

Haiken M. Caring.com. August 17, 2009.

STUDY

Helping patients simplify and safely use complex prescription regimens.

Wolf MS, Curtis LM, Waite K, et al. Arch Intern Med. 2011;171:300-305.

NEWSPAPER/MAGAZINE ARTICLE

Look-alike, sound-alike drugs trigger dangers.

Aleccia J. MSNBC.com; May 28, 2010.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: a year in review.

Institute for Safe Medication Practices. Pharmacy Practice News. October 2011:7-14.

FACT SHEET/FAQS

Ten Tips to Prevent an Accidental Overdose.

Silver Spring, MD: US Food and Drug Administration; May 2011.

BOOK/REPORT

Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease.

Cambridge, MA: New England Healthcare Institute; August 12, 2009.

NEWSPAPER/MAGAZINE ARTICLE

Baby's death spotlights safety risks linked to computerized systems.

Graham J, Dizikes C. Chicago Tribune. June 27, 2011.

NEWSPAPER/MAGAZINE ARTICLE

Nearly 90 major medical mistakes logged at Utah hospitals in 2008.

May H. Salt Lake Tribune. June 26, 2009.

NEWSPAPER/MAGAZINE ARTICLE

Parents sue over babies' heparin overdoses: infants were given too much heparin at Methodist Hospital.

Higgins W. Indianapolis Star. September 13, 2008;News section:A1

AUDIOVISUAL

Medication mix-ups.

Ross B. ABC News. March 1, 2010.

NEWSPAPER/MAGAZINE ARTICLE

No more blame & shame: developing event-reporting systems may go a long way to reducing patient care errors in EMS.

Rajasekaran K, Fairbanks RJ, Shah MN. EMS Magazine. September 2008.

AUDIOVISUAL

Nebraska Medical Center investigates staff after girl's death.

Luby R. KETV. Omaha, NE. March 31, 2010.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:1062-1065.

AUDIOVISUAL

Avoiding Medication Mistakes.

Fitzpatrick C. Consumer Updates. Silver Spring, MD: US Food and Drug Administration. September 29, 2009.

NEWSPAPER/MAGAZINE ARTICLE

'Alarm fatigue’ a factor in 2nd death.

Kowalczyk L. Boston Globe. September 21, 2011.

STUDY

Determinants of patient-reported medication errors: a comparison among seven countries.

Lu CY, Roughead E. Int J Clin Pract. 2011;65:733-740.

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