AHRQ Patient Safety Network

The Collection > Active Errors

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Safety Target

•Device-related Complications (62)

•Diagnostic Errors (154)

•Identification Errors (77)

•Discontinuities, Gaps, and Hand-Off Problems (120)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (446)

•Medical Complications (75)

•Nonsurgical Procedural Complications (37)

•Surgical Complications (144)

•Transfusion Complications (8)

•Psychological and Social Complications (43)

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•Africa (1)

•Asia (19)

•Australia and New Zealand (26)

•Central and South America (5)

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•Clinical Guideline (2)

•Journal Article (692)

•Legislation/Regulation (7)

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•Newspaper/Magazine Article (170)

•Press Release/Announcement (15)

•Special or Theme Issue (7)

•Tools/Toolkit (6)

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Error Types
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Active Errors

•Noncognitive Errors ("Slips & Lapses") (115)

•Cognitive Errors ("Mistakes") (149)

Approach to Improving Safety

•Quality Improvement Strategies (225)

•Legal and Policy Approaches (110)

•Error Reporting and Analysis (268)

•Communication Improvement (272)

•Human Factors Engineering (228)

•Teamwork (39)

•Specialization of Care (45)

•Logistical Approaches (58)

•Culture of Safety (68)

•Technologic Approaches (225)

•Education and Training (199)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (761)

•Health Care Executives and Administrators (671)

•Non-Health Care Professionals (312)

•Patients (117)

Setting of Care

•Hospitals (652)

•Psychiatric Facilities (4)

•Residential Facilities (15)

•Ambulatory Care (132)

•Outpatient Surgery (16)

•Patient Transport (11)

1 - 20 of 962

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STUDY

Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.

Tham E, Calmes HM, Poppy A, et al. Pediatrics. 2011;128:e438-e445.

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

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

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

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.

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

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:937-938, 945.

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.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:282-287.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:13-17.

STUDY

Origins of and solutions for neonatal medication-dispensing errors.

Sauberan JB, Dean LM, Fiedelak J, Abraham JA. Am J Health Syst Pharm. 2010;67:49-57.

MEASUREMENT TOOL/INDICATOR

Tubing Misconnections Self Assessment for Healthcare Facilities.

Horsham, PA: Institute for Safe Medication Practices, Deerfield, IL: Baxter Healthcare; 2012.

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.

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.

STUDY

Improving resident engagement in quality improvement and patient safety initiatives at the bedside: the Advocate for Clinical Education (ACE).

Schleyer AM, Best JA, McIntyre LK, Ehrmantraut R, Calver P, Goss JR. Am J Med Qual. 2012 Aug 20; [Epub ahead of print].

NEWSPAPER/MAGAZINE ARTICLE

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.

STUDY

What do hospital staff in the UK think are the causes of penicillin medication errors?

Wilcock M, Harding G, Moore L, Nicholls I, Powell N, Stratton J. Int J Clin Pharm. 2013;35:72-78.

NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

ISMP Medication Safety Alert! Acute Care Edition. May 3, 2007;12:1-2.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:18-21.

COMMENTARY classic

Balancing "no blame" with accountability in patient safety.

Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.

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.

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