AHRQ Patient Safety Network

The Collection > Noncognitive Errors ("Slips & Lapses")

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Safety Target

•Device-related Complications (9)

•Diagnostic Errors (23)

•Identification Errors (19)

•Discontinuities, Gaps, and Hand-Off Problems (56)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (63)

•Medical Complications (20)

•Nonsurgical Procedural Complications (3)

•Surgical Complications (28)

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•Psychological and Social Complications (10)

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•Asia (1)

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•Journal Article (142)

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•Newspaper/Magazine Article (20)

•Press Release/Announcement (1)

•Special or Theme Issue (1)

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Error Types
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Noncognitive Errors ("Slips & Lapses")

Approach to Improving Safety

•Quality Improvement Strategies (54)

•Legal and Policy Approaches (16)

•Error Reporting and Analysis (36)

•Communication Improvement (83)

•Human Factors Engineering (41)

•Teamwork (12)

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•Technologic Approaches (45)

•Education and Training (43)

Clinical Areas

•Medicine (141)

•Nursing (34)

•Pharmacy (18)

Target Audience

•Health Care Providers (146)

•Health Care Executives and Administrators (84)

•Non-Health Care Professionals (64)

•Patients (11)

Setting of Care

•Hospitals (130)

•Residential Facilities (3)

•Ambulatory Care (20)

•Outpatient Surgery (1)

•Patient Transport (2)

1 - 20 of 172

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STUDY

Contextual errors and failures in individualizing patient care: a multicenter study.

Weiner SJ, Schwartz A, Weaver F, et al. Ann Intern Med. 2010;153:69-75.

REVIEW

Interruptions and distractions in healthcare: review and reappraisal.

Rivera-Rodriguez AJ, Karsh BT. Qual Saf Health Care. 2010;19:304-312.

COMMENTARY classic

A piece of my mind. Copy-and-paste.

Hirschtick RE. JAMA. 2006;295:2335-2336.

COMMENTARY classic

Computerization can create safety hazards: a bar-coding near miss.

McDonald CJ. Ann Intern Med. 2006;144:510-516.

STUDY

Confidential clinician-reported surveillance of adverse events among medical inpatients.

Weingart SN, Ship AN, Aronson MD. J Gen Intern Med. 2000;15:470-477.

COMMENTARY classic

Error in medicine.

Leape LL. JAMA. 1994;272:1851-1857.

STUDY

Development of a checklist of safe discharge practices for hospital patients.

Soong C, Daub S, Lee J, et al. J Hosp Med. 2013 Mar 29; [Epub ahead of print].

REVIEW

Review of computerized physician handoff tools for improving the quality of patient care.

Li P, Ali S, Tang C, Ghali WA, Stelfox HT. J Hosp Med. 2012 Nov 20; [Epub ahead of print].

STUDY

The effects of a 'discharge time-out' on the quality of hospital discharge summaries.

Mohta N, Vaishnava P, Liang C, et al. BMJ Qual Saf. 2012;21:885-890.

STUDY

Intensive care unit nurses' information needs and recommendations for integrated displays to improve nurses' situation awareness.

Koch SH, Weir C, Haar M, et al. J Am Med Inform Assoc. 2012;19:583-590.

STUDY

High-priority drug–drug interactions for use in electronic health records.

Phansalkar S, Desai AA, Bell D, et al. J Am Med Inform Assoc. 2012;19:735-743.

STUDY

Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover.

Pickering BW, Hurley K, Marsh B. Crit Care Med. 2009;37:2905-2912.

STUDY

Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk.

Berkenstadt H, Haviv Y, Tuval A, et al. Chest. 2008;134:158-162.

STUDY

Medication prescribing errors involving the route of administration.

Lesar TS. Hosp Pharm. 2006;41:1053-1066.

MULTI-USE WEBSITE

Handover: Improving the Continuity of Patient Care Through Identification and Implementation of Novel Handover Processes in Europe.

University Medical Centre Utrecht.

MULTI-USE WEBSITE

Tubing and Luer Misconnections: Preventing Dangerous Medical Errors.

US Food and Drug Administration.

STUDY

Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program.

Graham KL, Marcantonio ER, Huang GC, Yang J, Davis RB, Smith CC. J Gen Intern Med. 2013 Apr 18; [Epub ahead of print].

COMMENTARY

Implementation of a specialized pharmacy team to monitor high-risk medications during discharge.

Martin ES III, Overstreet RL, Jackson-Khalil LR, McCollough HL, Meyer TA, Xu Q. Am J Health Syst Pharm. 2013;70:18-21.

SPECIAL OR THEME ISSUE

Handoff Communication Tools.

FIRST Do No Harm. December 2012;1-8.

STUDY

Momentary interruptions can derail the train of thought.

Altmann EM, Trafton JG, Hambrick DZ. J Exp Psychol Gen. 2013 Jan 7; [Epub ahead of print].

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