AHRQ Patient Safety Network

The Collection > Cognitive Errors ("Mistakes")

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Safety Target

•Device-related Complications (1)

•Diagnostic Errors (86)

•Identification Errors (6)

•Discontinuities, Gaps, and Hand-Off Problems (34)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (43)

•Medical Complications (6)

•Nonsurgical Procedural Complications (4)

•Surgical Complications (15)

•Transfusion Complications (1)

•Psychological and Social Complications (6)

Origin/Sponsor

•Asia (4)

•Australia and New Zealand (5)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (132)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (13)

•Press Release/Announcement (1)

•Web Resource (1)

Error Types
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Cognitive Errors ("Mistakes")

Approach to Improving Safety

•Quality Improvement Strategies (47)

•Legal and Policy Approaches (11)

•Error Reporting and Analysis (44)

•Communication Improvement (48)

•Human Factors Engineering (22)

•Teamwork (11)

•Specialization of Care (10)

•Logistical Approaches (11)

•Culture of Safety (11)

•Technologic Approaches (26)

•Education and Training (56)

Clinical Areas

Target Audience

•Health Care Providers (143)

•Health Care Executives and Administrators (67)

•Non-Health Care Professionals (51)

•Patients (10)

Setting of Care

•Hospitals (99)

•Psychiatric Facilities (3)

•Ambulatory Care (24)

1 - 20 of 156

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COMMENTARY

Discharge Fumbles.

Forster A. AHRQ WebM&M [serial online]. December 2004.

COMMENTARY

Missed Appendicitis.

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

STUDY

Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers.

Kachalia A, Gandhi TK, Puopolo AL, et al. Ann Emerg Med. Ann Emerg Med. 2007;49:196-205.

COMMENTARY

Getting to the Root of the Matter

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

COMMENTARY

The Worst Headache.

Edlow JA. AHRQ WebM&M [serial online]. July 2004.

COMMENTARY

The Dropped Lung.

Heffner JE. AHRQ WebM&M [serial online]. May 2003.

COMMENTARY

Undiagnosed Vaginal Bleeding.

Mandelblatt J. AHRQ WebM&M [serial online]. February 2004.

COMMENTARY

Deciphering the Code

Goldstein MK. AHRQ WebM&M [serial online]. Febuary 2006.

COMMENTARY

Surprise Wire

Pearl JM, Donaldson NE. AHRQ WebM&M [serial online]. July/August 2005.

COMMENTARY

Lethal Vertigo.

Furman JM. AHRQ WebM&M [serial online]. June 2004.

COMMENTARY

Lost in Transition

Beach C. AHRQ WebM&M [serial online]. Febuary 2006.

COMMENTARY

XL or Smaller?

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

STUDY

Surgeon commitment to trauma care decreases missed injuries.

Lin YK, Lin CJ, Chan HM, et al. Injury. 2012 Nov 3; [Epub ahead of print].

COMMENTARY

Premature or Overdue?

Thomas J, Hannah M. AHRQ WebM&M [serial online]. April 2003.

NEWSPAPER/MAGAZINE ARTICLE

Death of a boy prompts new medical efforts nationwide.

Dwyer J. New York Times. October 25, 2012.

COMMENTARY

Delay in Initiating Antibiotics Leads to Fatal Error.

Bellini LM. AHRQ WebM&M [serial online]. February 2004.

COMMENTARY

Pregnant with Danger.

Pearlman MD, Desmond JS. WebM&M [serial online]. May 2005.

COMMENTARY

Citrate Mix-Up

Weber RJ. AHRQ WebM&M [serial online]. May 2006.

STUDY

The effect of clinical history on accuracy of electrocardiograph interpretation among doctors working in emergency departments.

Cruz MF, Edwards J, Dinh DM, Barnes EH. Med J Aust. 2012;197:161-165.

COMMENTARY

Not a Miscarriage.

Learman LA. AHRQ WebM&M [serial online]. June 2003.

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