AHRQ Patient Safety Network

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

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Safety Target

•Device-related Complications (6)

•Diagnostic Errors (17)

•Identification Errors (11)

•Discontinuities, Gaps, and Hand-Off Problems (46)

•Medication Safety (45)

•Medical Complications (10)

•Nonsurgical Procedural Complications (2)

•Surgical Complications (18)

•Transfusion Complications (2)

•Psychological and Social Complications (7)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (4)

•Central and South America (1)

Resource Types

•Journal Article (106)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (13)

•Web Resource (3)

Error Types
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Noncognitive Errors ("Slips & Lapses")

Approach to Improving Safety

•Quality Improvement Strategies (39)

•Legal and Policy Approaches (10)

•Error Reporting and Analysis (25)

•Communication Improvement (65)

•Human Factors Engineering (32)

•Teamwork (9)

•Specialization of Care (7)

•Logistical Approaches (14)

•Culture of Safety (4)

•Technologic Approaches (31)

•Education and Training (31)

Clinical Areas

•Medicine (102)

•Nursing (26)

•Pharmacy (12)

Target Audience

•Health Care Providers (107)

•Health Care Executives and Administrators (73)

•Non-Health Care Professionals (45)

•Patients (8)

Setting of Care

•Hospitals (92)

•Residential Facilities (2)

•Ambulatory Care (14)

•Patient Transport (2)

1 - 20 of 125

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COMMENTARY

Right? Left? Neither!

Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.

COMMENTARY

Getting to the Root of the Matter

Flanders SA, Saint S. AHRQ WebM&M [serial online]. June 2005.

STUDY

Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO.'

Iedema R, Ball C, Daly B, et al. BMJ Qual Saf. 2012;21:627-633.

NEWSPAPER/MAGAZINE ARTICLE

Forgotten but not gone: tourniquets left on patients.

PA-PSRS Patient Saf Advis. June 2005;2:19-21.

COMMENTARY

Crossed Coverage

Kayser SR. AHRQ WebM&M [serial online]. February 2007.

COMMENTARY

In Conversation with…Sanjay Saint, MD, MPH

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

COMMENTARY

Code Status Confusion.

Lo B, Tulsky JA. AHRQ WebM&M [serial online]. July 2003.

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

Teamwork errors in trauma resuscitation.

Sarcevic A, Marsic I, Burd RS. ACM Trans Comput Hum Interact. 2012;19:13:1-13:30.

COMMENTARY

On O.R. Off?

Leonard M. AHRQ WebM&M [serial online]. March 2005.

COMMENTARY

Too Tight Control.

Rubin HR, Fajtova VT. AHRQ WebM&M [serial online]. May 2004.

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.

COMMENTARY

Around the Block.

Minichiello T. AHRQ WebM&M [serial online]. March 2005.

COMMENTARY

Thin Air.

Gaba DM. AHRQ WebM&M [serial online]. October 2004.

COMMENTARY

Another Fall.

Bogardus ST Jr. AHRQ WebM&M [serial online]. April 2003.

COMMENTARY

Hidden Mystery.

Brunette DD. AHRQ WebM&M [serial online]. March 2005.

COMMENTARY

A nurse-led approach to developing and implementing a collaborative count policy.

Norton EK, Micheli AJ, Gedney J, Felkerson TM. AORN J. 2012;95:222-227.

STUDY

Classifying laboratory incident reports to identify problems that jeopardize patient safety.

Astion ML, Shojania KG, Hamill TR, Kim S, Ng VL. Am J Clin Pathol. 2003;120:18-26.

COMMENTARY

Missed Appendicitis.

Adams JG. AHRQ WebM&M [serial online]. June 2003.

STUDY

Surgeons don't know what they don't know about the safe use of energy in surgery.

Feldman LS, Fuchshuber P, Jones DB, Mischna J, Schwaitzberg SD; FUSE (Fundamental Use of Surgical Energy) Task Force. Surg Endosc. 2012;26:2735-2739.

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