AHRQ Patient Safety Network

The Collection > Latent Errors

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Safety Target

•Device-related Complications (31)

•Diagnostic Errors (47)

•Identification Errors (24)

•Discontinuities, Gaps, and Hand-Off Problems (93)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (126)

•Medical Complications (30)

•Nonsurgical Procedural Complications (12)

•Surgical Complications (44)

•Transfusion Complications (3)

•Psychological and Social Complications (12)

Origin/Sponsor

•Africa (1)

•Asia (4)

•Australia and New Zealand (10)

Resource Types

•Journal Article (280)

•Legislation/Regulation (7)

•Meeting/Conference (1)

•Newspaper/Magazine Article (53)

•Press Release/Announcement (8)

•Special or Theme Issue (4)

•Tools/Toolkit (4)

•Web Resource (8)

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Latent Errors

Approach to Improving Safety

•Quality Improvement Strategies (98)

•Legal and Policy Approaches (59)

•Error Reporting and Analysis (121)

•Communication Improvement (127)

•Human Factors Engineering (110)

•Teamwork (27)

•Specialization of Care (18)

•Logistical Approaches (43)

•Culture of Safety (66)

•Technologic Approaches (87)

•Education and Training (77)

Clinical Areas

•Allied Health Services (5)

•Medicine (288)

•Nursing (46)

•Pharmacy (51)

Target Audience

•Health Care Providers (297)

•Health Care Executives and Administrators (286)

•Non-Health Care Professionals (178)

•Patients (37)

Setting of Care

•Hospitals (264)

•Psychiatric Facilities (1)

•Residential Facilities (8)

•Ambulatory Care (40)

•Outpatient Surgery (4)

•Patient Transport (4)

1 - 20 of 396

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COMMENTARY

Double Dosing, by the Rules

Cohen H. AHRQ WebM&M [serial online]. February/March 2009.

COMMENTARY

All in the History

Fee C. AHRQ WebM&M [serial online]. February/March 2009.

STUDY

Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.

Kaplan LJ, Maerz LL, Schuster K, et al. J Trauma. 2009;67:173-179.

COMMENTARY

Moving Pains

Schell H, Wachter RM. AHRQ WebM&M [serial online]. July 2006.

COMMENTARY

To LP or not LP.

Landrigan CP. AHRQ WebM&M [serial online]. October 2003.

COMMENTARY

Where’s the Feeding Tube?

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

BOOK/REPORT

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.

Toft B. London, England: Department of Health; 2001.

NEWSPAPER/MAGAZINE ARTICLE

Baby's death spotlights safety risks linked to computerized systems.

Graham J, Dizikes C. Chicago Tribune. June 27, 2011.

COMMENTARY

Do Not Disturb!

Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.

STUDY

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit.

Stavroudis TA, Shore AD, Morlock L, Hicks RW, Bundy D, Miller MR. J Perinatol. 2010;30:459-468.

COMMENTARY

The Dangerous Detour.

Gibson J, Taylor D. AHRQ WebM&M [serial online]. June 2003.

STUDY

Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.

Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Qual Saf Health Care. 2005;14:401-407.

COMMENTARY

Language Barrier

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

COMMENTARY

Achieving the 'perfect handoff' in patient transfers: building teamwork and trust.

Clarke D, Werestiuk K, Schoffner A, et al. J Nurs Manag. 2012;20:592-598.

REVIEW

Medical error and decision making: learning from the past and present in intensive care.

Bucknall TK. Aust Crit Care. 2010;23:150-156.

STUDY

Simulator-based crew resource management training for interhospital transfer of critically ill patients by a mobile ICU.

Droogh JM, Kruger HL, Ligtenberg JJM, Zijlstra JG. Jt Comm J Qual Patient Saf. 2012;38:554-559.

COMMENTARY

Staggered Sensitivity Results

Guglielmo BJ. AHRQ WebM&M [serial online]. March 2007.

COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

COMMENTARY

Code Blue—Where To?

Adams BD. AHRQ WebM&M [serial online]. October 2007.

STUDY

Medical errors recovered by critical care nurses.

Dykes PC, Rothschild JM, Hurley AC. J Nurs Adm. 2010;40:241-246.

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