AHRQ Patient Safety Network

The Collection > Active Errors

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Safety Target

•Device-related Complications (59)

•Diagnostic Errors (162)

•Identification Errors (79)

•Discontinuities, Gaps, and Hand-Off Problems (123)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (422)

•Medical Complications (75)

•Nonsurgical Procedural Complications (38)

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Active Errors

•Noncognitive Errors ("Slips & Lapses") (95)

•Cognitive Errors ("Mistakes") (144)

Approach to Improving Safety

•Quality Improvement Strategies (229)

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Clinical Areas

•Allied Health Services (6)

•Medicine (732)

•Nursing (96)

•Pharmacy (150)

Target Audience

•Health Care Providers (750)

•Health Care Executives and Administrators (666)

•Non-Health Care Professionals (303)

•Patients (110)

Setting of Care

•Hospitals (633)

•Psychiatric Facilities (4)

•Residential Facilities (12)

•Ambulatory Care (131)

•Outpatient Surgery (17)

•Patient Transport (14)

1 - 20 of 948

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STUDY

Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial.

Terrell KM, Perkins AJ, Hui SL, Callahan CM, Dexter PR, Miller DK. Ann Emerg Med. 2010;56:623-629.

STUDY

An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies.

Palchuk MB, Fang EA, Cygielnik JM, et al. J Am Med Inform Assoc. 2010;17:472-476.

REVIEW

Year in review: medication mishaps in the elderly.

Peron EP, Marcum ZA, Boyce R, Hanlon JT, Handler SM. Am J Geriatr Pharmacother. 2011;9:1-10.

STUDY

Critical drug–drug interactions for use in electronic health records systems with computerized physician order entry: review of leading approaches.

Classen DC, Phansalkar S, Bates DW. J Patient Saf. 2011;7:61-65.

STUDY

Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration.

Yamamoto L, Kanemori J. Am J Emerg Med. 2010;28:588-592.

STUDY

ED overcrowding is associated with an increased frequency of medication errors.

Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. Am J Emerg Med. 2010;28:304-309.

STUDY

Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system.

Mattison MLP, Afonso KA, Ngo LH, Mukamal KJ. Arch Intern Med. 2010;170:1331-1336.

STUDY

Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents.

Redwood S, Rajakumar A, Hodson J, Coleman JJ. BMC Med Inform Decis Mak. 2011;11:29.

STUDY

Accuracy of radiographic readings in the emergency department.

Petinaux B, Bhat R, Boniface K, Aristizabal J. Am J Emerg Med. 2011;29:18-25.

COMMENTARY

Recurrent Hypoglycemia: A Care Transition Failure?

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

STUDY

Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety.

Collins CM, Elsaid KA. Int J Qual Health Care. 2011;23:36-43.

STUDY

A "back to basics" approach to reduce ED medication errors.

Blank FSJ, Tobin J, Macomber S, Jaouen M, Dinoia M, Visintainer P. J Emerg Nurs. 2011;37:141-147.

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.

STUDY

Medication errors recovered by emergency department pharmacists.

Rothschild JM, Churchill W, Erickson A, et al. Ann Emerg Med. 2010;55:513-521.

STUDY

Physician order entry or nurse order entry? Comparison of two implementation strategies for a computerized order entry system aimed at reducing dosing medication errors.

Kazemi A, Fors UG, Tofighi S, Tessma M, Ellenius J. J Med Internet Res. 2010;12:e5.

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.

COMMENTARY

Sick and Pregnant

El-Ibiary S. AHRQ WebM&M [serial online]. November 2008.

STUDY

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.

STUDY

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

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

COMMENTARY

A Mid-Summer Fog

Braddock CH. AHRQ WebM&M [serial online]. November 2008.

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