AHRQ Patient Safety Network

The Collection > Active Errors

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Safety Target

•Device-related Complications (54)

•Diagnostic Errors (95)

•Identification Errors (65)

•Discontinuities, Gaps, and Hand-Off Problems (84)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (283)

•Medical Complications (64)

•Nonsurgical Procedural Complications (28)

•Surgical Complications (175)

•Transfusion Complications (3)

•Psychological and Social Complications (35)

Origin/Sponsor

•Africa (1)

•Asia (3)

•Australia and New Zealand (14)

Resource Types

•Clinical Guideline (3)

•Journal Article (456)

•Legislation/Regulation (5)

•Meeting/Conference (1)

•Newspaper/Magazine Article (162)

•Press Release/Announcement (7)

•Special or Theme Issue (6)

•Tools/Toolkit (5)

•Web Resource (7)

•Grant (1)

Error Types
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Active Errors

•Noncognitive Errors ("Slips & Lapses") (56)

•Cognitive Errors ("Mistakes") (91)

Approach to Improving Safety

•Quality Improvement Strategies (164)

•Legal and Policy Approaches (103)

•Error Reporting and Analysis (185)

•Communication Improvement (230)

•Human Factors Engineering (165)

•Teamwork (41)

•Specialization of Care (26)

•Logistical Approaches (37)

•Culture of Safety (50)

•Technologic Approaches (141)

•Education and Training (181)

Clinical Areas

•Allied Health Services (6)

Target Audience

•Health Care Providers (523)

•Health Care Executives and Administrators (454)

•Non-Health Care Professionals (204)

•Patients (134)

Setting of Care

•Hospitals (470)

•Psychiatric Facilities (1)

•Residential Facilities (12)

•Ambulatory Care (90)

•Outpatient Surgery (16)

•Patient Transport (8)

1 - 20 of 699

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NEWSPAPER/MAGAZINE ARTICLE

A pinpoint beam strays invisibly, harming instead of healing.

Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.

NEWSPAPER/MAGAZINE ARTICLE

The wrong foot, and other tales of surgical error.

Altman LK. New York Times. December 11, 2001;1:1.

COMMENTARY

Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy.

Bellandi T, Albolino S, Tartaglia R, Filipponi F. Transplant Proc. 2010;42:2187-2189.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

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

NEWSPAPER/MAGAZINE ARTICLE

The pain of wrong site surgery.

Boodman SG. Washington Post. June 21, 2011:E1.

NEWSPAPER/MAGAZINE ARTICLE

Entire UPMC transplant team missed hepatitis alert.

Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.

NEWSPAPER/MAGAZINE ARTICLE

A towel with a safety message.

Lerner M. Minneapolis Star Tribune. January 25, 2009:B1.

ORGANIZATIONAL POLICY/GUIDELINES

Safe Site Invasive Procedure—Non-Operating Room.

Bloomington, MN: Institute for Clinical Systems Improvement; 2010.

COMMENTARY

Retained surgical items and minimally invasive surgery.

Gibbs VC. World J Surg. 2011;35:1532-1539.

STUDY

Failure to rescue as a process measure to evaluate fetal safety during labor.

Beaulieu MJ. MCN Am J Matern Child Nurs. 2009;34:18-23.

REVIEW

A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery.

Borchard A, Schwappach DL, Barbir A, Bezzola P. Ann Surg. 2012;256:925-933.

COMMENTARY

System errors in intrapartum electronic fetal monitoring: a case review.

Miller LA. J Midwifery Womens Health. 2005;50:507-516.

AUDIOVISUAL

Nebraska Medical Center investigates staff after girl's death.

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

STUDY

Violations of behavioral practices revealed in closed claims reviews.

Griffen FD, Stephens LS, Alexander JB, et al. Ann Surg. 2008;248:468-474.

STUDY

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

COMMENTARY

Beeline to Spine

Smetana GW. AHRQ WebM&M [serial online]. June 2007.

BOOK/REPORT

Acting on Concerns: Your Professional Responsibility.

Shale S; The Royal College of Surgeons of England. London, UK: RCSENG Communications; 2013.

NEWSPAPER/MAGAZINE ARTICLE

Night shift nightmare.

Alexander M. Reader's Digest. June 2007.

NEWSPAPER/MAGAZINE ARTICLE

Doctor removes ovaries from wrong patient.

Bramson K, Mooney T. Providence Journal. August 18, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Revealing their medical errors: why three doctors went public.

O'Reilly KB. American Medical News. August 15, 2011.

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