AHRQ Patient Safety Network

The Collection > Active Errors

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Safety Target

•Device-related Complications (57)

•Diagnostic Errors (98)

•Identification Errors (62)

•Discontinuities, Gaps, and Hand-Off Problems (93)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (328)

•Medical Complications (56)

•Nonsurgical Procedural Complications (25)

•Surgical Complications (114)

•Transfusion Complications (6)

•Psychological and Social Complications (34)

Origin/Sponsor

•Asia (7)

•Australia and New Zealand (16)

•Central and South America (1)

Resource Types

•Clinical Guideline (2)

•Journal Article (509)

•Legislation/Regulation (5)

•Meeting/Conference (1)

•Newspaper/Magazine Article (155)

•Press Release/Announcement (4)

•Special or Theme Issue (5)

•Tools/Toolkit (5)

•Web Resource (10)

•Grant (1)

Error Types
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Active Errors

•Noncognitive Errors ("Slips & Lapses") (60)

•Cognitive Errors ("Mistakes") (75)

Approach to Improving Safety

•Quality Improvement Strategies (172)

•Legal and Policy Approaches (98)

•Error Reporting and Analysis (225)

•Communication Improvement (216)

•Human Factors Engineering (163)

•Teamwork (30)

•Specialization of Care (31)

•Logistical Approaches (45)

•Culture of Safety (63)

•Technologic Approaches (161)

•Education and Training (149)

Clinical Areas

•Allied Health Services (7)

•Medicine (566)

•Nursing (96)

•Pharmacy (118)

Target Audience

•Health Care Providers (565)

•Health Care Executives and Administrators (529)

•Non-Health Care Professionals (231)

•Patients (101)

Setting of Care

•Hospitals (507)

•Psychiatric Facilities (3)

•Residential Facilities (13)

•Ambulatory Care (105)

•Outpatient Surgery (14)

•Patient Transport (11)

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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.

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.

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.

AWARD RECIPIENT

The MacArthur Fellows Program: Eric Coleman.

The John D. and Catherine T. MacArthur Foundation. October 3, 2012.

COMMENTARY

Anatomy of an incident disclosure: the importance of dialogue.

Iedema R, Allen S. Jt Comm J Qual Patient Saf. 2012;38:435-442.

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

'Alarm fatigue’ a factor in 2nd death.

Kowalczyk L. Boston Globe. September 21, 2011.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals tally their avoidable mistakes.

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

BOOK/REPORT

Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems.

Glenview, IL: National Association of Healthcare Quality; October 2012.

REVIEW

Negligence, genuine error, and litigation.

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

COMMENTARY

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

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

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

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

COMMENTARY

Physicians with multiple patient complaints: ending our silence.

Gallagher TH, Levinson W. BMJ Qual Saf. 2013 Apr 18; [Epub ahead of print].

STUDY

Medication safety initiative in reducing medication errors.

Nguyen EE, Connolly PM, Wong V. J Nurs Care Qual. 2010;25:224-230.

NEWSPAPER/MAGAZINE ARTICLE

The 'second victims' of medication errors begin to gain support.

Blum K. Pharm Pract News. November 2011.

NEWSPAPER/MAGAZINE ARTICLE

MRI safety 10 years later.

Gilk T, Latino RJ. Patient Saf Qual Healthc. November/December 2011;8:22-23,26-29.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals leery of reporting serious errors.

Bernhard B, Kohler J. St. Louis Post-Dispatch. February 27, 2011:A1.

COMMENTARY

Learning accountability for patient outcomes.

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

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

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