AHRQ Patient Safety Network

The Collection > Cognitive Errors ("Mistakes")

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Safety Target

•Device-related Complications (6)

•Diagnostic Errors (78)

•Identification Errors (8)

•Discontinuities, Gaps, and Hand-Off Problems (26)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (61)

•Medical Complications (7)

•Nonsurgical Procedural Complications (7)

•Surgical Complications (15)

•Transfusion Complications (1)

•Psychological and Social Complications (7)

Origin/Sponsor

•Africa (1)

•Asia (5)

•Australia and New Zealand (5)

•Central and South America (2)

Resource Types

•Journal Article (133)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (19)

•Press Release/Announcement (5)

•Special or Theme Issue (1)

Error Types
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Cognitive Errors ("Mistakes")

Approach to Improving Safety

•Quality Improvement Strategies (39)

•Legal and Policy Approaches (13)

•Error Reporting and Analysis (47)

•Communication Improvement (39)

•Human Factors Engineering (40)

•Teamwork (8)

•Specialization of Care (12)

•Logistical Approaches (11)

•Culture of Safety (14)

•Technologic Approaches (25)

•Education and Training (55)

Clinical Areas

Target Audience

•Health Care Providers (147)

•Health Care Executives and Administrators (80)

•Non-Health Care Professionals (54)

•Patients (12)

Setting of Care

•Hospitals (111)

•Psychiatric Facilities (3)

•Ambulatory Care (24)

•Outpatient Surgery (1)

1 - 20 of 165

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COMMENTARY

Weighing in on medication safety.

Paparella S. J Emerg Nurs. 2009;35:553-555.

NEWSPAPER/MAGAZINE ARTICLE

Heparin overdose in three infants revisits hospital error issues.

Phend C. MedPage Today. November 26, 2007.

STUDY

Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ?

Hobgood C, Weiner B, Tamayo-Sarver JH. Acad Emerg Med. 2006;13:443-451.

STUDY

Identifying medical errors: developing consensus on classifications and consequences.

Hobgood C, Eaton J, Weiner BJ. J Patient Saf. 2005;1:138-144.

COMMENTARY

Don't Push.

Meltzer HY. AHRQ WebM&M [serial online]. November 2003.

COMMENTARY

Lethal Vertigo.

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

COMMENTARY

Missed Appendicitis.

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

COMMENTARY

Triage Time Bomb.

Washington DL. AHRQ WebM&M [serial online]. January 2004.

COMMENTARY

Profiles in patient safety: a "perfect storm" in the emergency department.

Campbell SG, Croskerry P, Bond WF. Acad Emerg Med. 2007;14:743-9.

COMMENTARY

Lost in Transition

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

COMMENTARY

Undiagnosed Vaginal Bleeding.

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

COMMENTARY

Duplication of surgical site marking.

Davis JS, Karmacharya J, Schulman CI. J Patient Saf. 2012;8:151-152.

COMMENTARY

Charcoal Lavage of the Lungs.

Wigton RS. AHRQ WebM&M [serial online]. October 2003.

STUDY

Correlates of diagnostic accuracy in patients with nonspecific complaints.

Hertwig R, Meier N, Nickel C, et al. Med Decis Making. 2013;33:533-543.

COMMENTARY

On the Other Hand

Henneman EA. AHRQ WebM&M [serial online]. May 2007.

PRESS RELEASE/ANNOUNCEMENT

New dosing recommendations to prevent potential Valcyte (valganciclovir) overdose in pediatric transplant patients.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 15, 2010.

COMMENTARY

Ruptured Heterotopic Pregnancy.

Cedars MI. AHRQ WebM&M [serial online]. January 2004.

COMMENTARY

Autopsy Revelation.

Shojania KG. AHRQ WebM&M [serial online]. March 2004.

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

Discharge Fumbles.

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

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