AHRQ Patient Safety Network

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

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Safety Target

•Device-related Complications (8)

•Diagnostic Errors (16)

•Identification Errors (16)

•Discontinuities, Gaps, and Hand-Off Problems (52)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (55)

•Medical Complications (18)

•Nonsurgical Procedural Complications (2)

•Surgical Complications (21)

•Transfusion Complications (2)

•Psychological and Social Complications (9)

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•Asia (1)

•Australia and New Zealand (4)

•Central and South America (1)

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•Journal Article (122)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (17)

•Press Release/Announcement (1)

•Special or Theme Issue (1)

•Web Resource (3)

Error Types
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Noncognitive Errors ("Slips & Lapses")

Approach to Improving Safety

•Quality Improvement Strategies (45)

•Legal and Policy Approaches (14)

•Error Reporting and Analysis (32)

•Communication Improvement (68)

•Human Factors Engineering (34)

•Teamwork (10)

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•Logistical Approaches (18)

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•Technologic Approaches (42)

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Clinical Areas

•Medicine (122)

•Nursing (32)

•Pharmacy (16)

Target Audience

•Health Care Providers (127)

•Health Care Executives and Administrators (73)

•Non-Health Care Professionals (59)

•Patients (10)

Setting of Care

•Hospitals (116)

•Residential Facilities (3)

•Ambulatory Care (15)

•Outpatient Surgery (1)

•Patient Transport (1)

1 - 20 of 147

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COMMENTARY

Patient Mix-Up.

Shojania KG. AHRQ WebM&M [serial online]. February 2003.

COMMENTARY

Glucose Roller Coaster.

Sharpe BA. AHRQ WebM&M [serial online]. July 2004.

NEWSPAPER/MAGAZINE ARTICLE

State: nurse error caused death.

Wahlberg D. Wisconsin State Journal. July 22, 2006:A1.

COMMENTARY

Check the Bags.

Caldwell M, Dracup KA. AHRQ WebM&M [serial online]. September 2003.

COMMENTARY

Workaround Error

Pape T. AHRQ WebM&M [serial online]. Febuary 2006.

COMMENTARY

The Result Stopped Here.

Astion M. AHRQ WebM&M [serial online]. June 2004.

STUDY

Do staffing levels predict missed nursing care?

Kalisch BJ, Tschannen D, Lee KH. Int J Qual Health Care. 2011;23:302-308.

COMMENTARY

40 of K.

Lesar TS. AHRQ WebM&M [serial online]. November 2003.

COMMENTARY

XL or Smaller?

Kozer E. AHRQ WebM&M [serial online]. June 2003.

COMMENTARY

Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements.

DeRienzo CM, Frush K, Barfield ME, et al. Acad Med. 2012;87:403-410.

COMMENTARY

Thin Air.

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

COMMENTARY

Bleeding Risk.

Crowther MA. AHRQ WebM&M [serial online]. July 2003.

STUDY

Errors in the administration of intravenous medication in Brazilian hospitals.

Anselmi ML, Peduzzi M, Dos Santos CB. J Clin Nurs. 2007;16:1839-1847.

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.

COMMENTARY

Cups of Error

Blegen MA, Pepper GA. AHRQ WebM&M [serial online]. May 2006.

COMMENTARY

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

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

STUDY

Learning from error: identifying contributory causes of medication errors in an Australian hospital.

Nichols P, Copeland T-S, Craib IA, Hopkins P, Bruce DG. Med J Aust. 2008;188:276-279.

COMMENTARY

Feeling No Pain.

Bogner MS. AHRQ WebM&M [serial online]. July 2003.

COMMENTARY

Right Patient, Wrong Sample

Astion M. AHRQ WebM&M [serial online]. December 2006.

COMMENTARY

Lost in the Black Hole.

Wachter RM. AHRQ WebM&M [serial online]. October 2003.

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