AHRQ Patient Safety Network

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

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Safety Target

•Device-related Complications (8)

•Diagnostic Errors (20)

•Identification Errors (15)

•Discontinuities, Gaps, and Hand-Off Problems (55)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (55)

•Medical Complications (17)

•Nonsurgical Procedural Complications (3)

•Surgical Complications (21)

•Transfusion Complications (2)

•Psychological and Social Complications (9)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (4)

•Central and South America (1)

Resource Types

•Journal Article (123)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (22)

•Special or Theme Issue (1)

•Web Resource (2)

Error Types
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Noncognitive Errors ("Slips & Lapses")

Approach to Improving Safety

•Quality Improvement Strategies (47)

•Legal and Policy Approaches (15)

•Error Reporting and Analysis (29)

•Communication Improvement (72)

•Human Factors Engineering (33)

•Teamwork (9)

•Specialization of Care (10)

•Logistical Approaches (18)

•Culture of Safety (6)

•Technologic Approaches (39)

•Education and Training (32)

Clinical Areas

•Medicine (125)

•Nursing (30)

•Pharmacy (17)

Target Audience

•Health Care Providers (127)

•Health Care Executives and Administrators (79)

•Non-Health Care Professionals (52)

•Patients (10)

Setting of Care

•Hospitals (116)

•Residential Facilities (3)

•Ambulatory Care (17)

•Outpatient Surgery (1)

•Patient Transport (1)

1 - 20 of 153

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STUDY

An institution-wide handoff task force to standardise and improve physician handoffs.

Horwitz LI, Schuster KM, Thung SF, et al. BMJ Qual Saf. 2012;21:863-871.

STUDY

The importance of preparation for doctors' handovers in an acute medical assessment unit: a hierarchical task analysis.

Raduma-Tomàs MA, Flin R, Yule S, Close S. BMJ Qual Saf. 2012;21:211-217.

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.

MULTI-USE WEBSITE

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

University Medical Centre Utrecht.

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.

MULTI-USE WEBSITE

Aware in Care.

Miami, FL: National Parkinson Foundation; October 2012.

COMMENTARY

Infusing fun into quality and safety initiatives.

Foulk KC, Tocydlowski P, Snow TM, et al. Nursing. 2012;42:14-16.

COMMENTARY

A performance improvement plan to increase nurse adherence to use of medication safety software.

Gavriloff C. J Pediatr Nurs. 2012;27:375-382.

SPECIAL OR THEME ISSUE

Handoff Communication Tools.

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

NEWSPAPER/MAGAZINE ARTICLE

Doctors' smartphones and iPads may be distracting.

Gold J. Kaiser Health News and National Public Radio. March 26, 2012.

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].

NEWSPAPER/MAGAZINE ARTICLE

Administering a saline flush "site unseen" can lead to a wrong route error.

ISMP Medication Safety Alert! Acute Care Edition. May 16, 2013;18:1-3.

COMMENTARY

Hidden Mystery.

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

STUDY

Handoff communication between hospital and outpatient dialysis units at patient discharge: a qualitative study.

Reilly JB, Marcotte LM, Berns JS, Shea JA. Jt Comm J Qual Patient Saf. 2013;39:70-76.

NEWSPAPER/MAGAZINE ARTICLE

Medication reconciliation meets its MATCH.

Agency for Healthcare Research and Quality. Research Activities. May 2013:1, 3-4.

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.

STUDY

Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.

Lee JY, Leblanc K, Fernandes OA, et al. Ann Pharmacother. 2010;44:1887-1895.

NEWSPAPER/MAGAZINE ARTICLE

With money at risk, hospitals push staff to wash hands.

Hartcollis A. New York Times. May 29, 2013:A18.

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