AHRQ Patient Safety Network

The Collection > Latent Errors

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Safety Target

•Device-related Complications (35)

•Diagnostic Errors (29)

•Identification Errors (17)

•Discontinuities, Gaps, and Hand-Off Problems (79)

•Fatigue and Sleep Deprivation (10)

•Medication Safety (133)

•Medical Complications (27)

•Nonsurgical Procedural Complications (12)

•Surgical Complications (45)

•Transfusion Complications (3)

•Psychological and Social Complications (11)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (6)

Resource Types

•Clinical Guideline (1)

•Journal Article (281)

•Legislation/Regulation (6)

•Meeting/Conference (1)

•Newspaper/Magazine Article (71)

•Press Release/Announcement (4)

•Special or Theme Issue (3)

•Tools/Toolkit (4)

•Web Resource (8)

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Latent Errors

Approach to Improving Safety

•Quality Improvement Strategies (88)

•Legal and Policy Approaches (66)

•Error Reporting and Analysis (119)

•Communication Improvement (108)

•Human Factors Engineering (101)

•Teamwork (24)

•Specialization of Care (11)

•Logistical Approaches (53)

•Culture of Safety (72)

•Technologic Approaches (81)

•Education and Training (69)

Clinical Areas

•Allied Health Services (5)

•Medicine (279)

•Nursing (58)

•Pharmacy (57)

Target Audience

•Health Care Providers (285)

•Health Care Executives and Administrators (307)

•Non-Health Care Professionals (178)

•Patients (50)

Setting of Care

•Hospitals (276)

•Psychiatric Facilities (1)

•Residential Facilities (11)

•Ambulatory Care (36)

•Outpatient Surgery (3)

•Patient Transport (4)

1 - 20 of 411

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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.

STUDY

Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.

Colligan L, Guerlain S, Steck SE, Hoke TR. BMJ Qual Saf. 2012;21:939-947.

COMMENTARY

Wrong Route for Nutrients

Scott-Cawiezell JR, AHRQ WebM&M [serial online]. July 2008.

NEWSPAPER/MAGAZINE ARTICLE

When surgery goes wrong: weighing up the risks.

Feinmann J. The Independent. November 14, 2006.

STUDY

"Did I do as best as the system would let me?" Healthcare professional views on hospital to home care transitions.

Davis MM, Devoe M, Kansagara D, Nicolaidis C, Englander H. J Gen Intern Med. 2012;27:1649-1656.

ORGANIZATIONAL POLICY/GUIDELINES

Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society.

Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF. J Am Coll Surg. 2012;215:453-466.

NEWSPAPER/MAGAZINE ARTICLE

Fatal drug mix-up exposes hospital flaws.

Davies T. Washington Post. September 22, 2006.

STUDY

Failure to rescue as a process measure to evaluate fetal safety during labor.

Beaulieu MJ. MCN Am J Matern Child Nurs. 2009;34:18-23.

STUDY

Bar-code technology for medication administration: medication errors and nurse satisfaction.

Fowler SB, Sohler P, Zarillo DF. MedSurg Nursing. 2009;18:103-110.

COMMENTARY

It's All in the Syringe

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

COMMENTARY

Crossed Coverage

Kayser SR. AHRQ WebM&M [serial online]. February 2007.

COMMENTARY

Patient safety in plastic surgery.

Trussler AP, Tabbal GN. Plast Reconstr Surg. 2012;130:470e-478e.

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.

COMMENTARY

Thin Air.

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

NEWSPAPER/MAGAZINE ARTICLE

Epidural-IV route mix-ups: reducing the risk of deadly errors.

ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.

COMMENTARY

Cups of Error

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

NEWSPAPER/MAGAZINE ARTICLE

Ding-a-ling-a-ling: ambulances can be dangerous places.

Meisel Z. Slate. November 8, 2005.

STUDY

Interruption handling strategies during paediatric medication administration.

Colligan L, Bass EJ. BMJ Qual Saf. 2012;21:912-917.

REVIEW

Clinical dilemmas and a review of strategies to manage drug shortages.

Rider AE, Templet DJ, Daley MJ, Shuman C, Smith LV. J Pharm Pract. 2013;26:183-191.

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.

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