AHRQ Patient Safety Network

The Collection > Latent Errors

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Safety Target

•Device-related Complications (34)

•Diagnostic Errors (43)

•Identification Errors (15)

•Discontinuities, Gaps, and Hand-Off Problems (61)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (89)

•Medical Complications (21)

•Nonsurgical Procedural Complications (11)

•Surgical Complications (40)

•Transfusion Complications (3)

•Psychological and Social Complications (10)

Origin/Sponsor

•Africa (1)

•Asia (4)

•Australia and New Zealand (5)

Resource Types

•Journal Article (199)

•Legislation/Regulation (2)

•Meeting/Conference (1)

•Newspaper/Magazine Article (37)

•Press Release/Announcement (3)

•Special or Theme Issue (2)

•Tools/Toolkit (4)

•Web Resource (4)

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Latent Errors

Approach to Improving Safety

•Quality Improvement Strategies (90)

•Legal and Policy Approaches (43)

•Error Reporting and Analysis (90)

•Communication Improvement (87)

•Human Factors Engineering (74)

•Teamwork (18)

•Specialization of Care (10)

•Logistical Approaches (32)

•Culture of Safety (41)

•Technologic Approaches (59)

•Education and Training (61)

Clinical Areas

•Allied Health Services (4)

•Medicine (198)

•Nursing (36)

•Pharmacy (36)

Target Audience

•Health Care Providers (213)

•Health Care Executives and Administrators (187)

•Non-Health Care Professionals (103)

•Patients (29)

Setting of Care

•Hospitals (184)

•Residential Facilities (6)

•Ambulatory Care (37)

•Outpatient Surgery (3)

•Patient Transport (4)

1 - 20 of 273

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COMMENTARY

Where’s the Feeding Tube?

Metheny MA., Meert KL, AHRQ WebM&M [serial online]. September 2008.

COMMENTARY

It's All in the Syringe

Weingart SN. AHRQ WebM&M [serial online]. August 2006.

COMMENTARY

Undiagnosed Vaginal Bleeding.

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

COMMENTARY

Language Barrier

Flores G. AHRQ WebM&M [serial online]. April 2006.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

COMMENTARY

Flying Object Hits MRI.

Gosbee J, Gosbee LL. AHRQ WebM&M [serial online]. February 2003.

STUDY

Errors of diagnosis in pediatric practice: a multisite survey.

Singh H, Thomas EJ, Wilson L, et al. Pediatrics. 2010;126:70-79.

STUDY

Nature, causes and consequences of unintended events in surgical units.

van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Br J Surg. 2010;97:1730-1740.

COMMENTARY

Patient Safety: A Perspective from Office Practice.

Baron RJ. AHRQ WebM&M [serial online]. May 2009.

STUDY

Novel analysis of clinically relevant diagnostic errors in point-of-care devices.

Shermock KM, Streiff MB, Pinto BL, Kraus P, Pronovost PJ. J Thromb Haemost. 2011;9:1769-1775.

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.

NEWSPAPER/MAGAZINE ARTICLE

Loud wake-up call: unlabeled containers lead to patient’s death.

ISMP Medication Safety Alert! Acute Care Edition. December 1, 2004;9:1-3.

COMMENTARY

Urine a Tough Position.

Gandhi TK. AHRQ WebM&M [serial online]. October 2003.

NEWSPAPER/MAGAZINE ARTICLE

Preventing catheter/tubing misconnections: much needed help is on the way.

ISMP Medication Safety Alert! Acute Care Edition. July 15, 2010;15:1-2.

REVIEW

Nature of human error: implications for surgical practice.

Cuschieri A. Ann Surg. 2006;244:642-648.

REVIEW

Overriding of drug safety alerts in computerized physician order entry.

van der Sijs H, Aarts J, Vulto A, Berg M. J Am Med Inform Assoc. 2006;13:138-147.

COMMENTARY

Profiles in patient safety: misplaced femoral line guidewire and multiple failures to detect the foreign body on chest radiography.

Lum TE, Fairbanks RJ, Pennington EC, Zwemer FL. Acad Emerg Med. 2005;12:658-662.

BOOK/REPORT classic

When Things Go Wrong: Responding to Adverse Events.

A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.

BOOK/REPORT

Report 6: Managing Risk and Minimising Mistakes in Services to Children and Families.

Bostock L, Bairstow S, Fish S, Macleod F. London, England: Social Care Institute for Excellence; 2005. ISBN: 1904812279.

STUDY

'Tempos' management in primary care: a key factor for classifying adverse events, and improving quality and safety.

Amalberti R, Brami J. BMJ Qual Saf. 2012;21:729-736.

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