AHRQ Patient Safety Network

The Collection > Latent Errors

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Safety Target

•Device-related Complications (35)

•Diagnostic Errors (49)

•Identification Errors (24)

•Discontinuities, Gaps, and Hand-Off Problems (96)

•Fatigue and Sleep Deprivation (10)

•Medication Safety (141)

•Medical Complications (30)

•Nonsurgical Procedural Complications (14)

•Surgical Complications (49)

•Transfusion Complications (3)

•Psychological and Social Complications (16)

Origin/Sponsor

•Africa (1)

•Asia (5)

•Australia and New Zealand (7)

Resource Types

•Clinical Guideline (1)

•Journal Article (313)

•Legislation/Regulation (8)

•Meeting/Conference (1)

•Newspaper/Magazine Article (69)

•Press Release/Announcement (5)

•Special or Theme Issue (4)

•Tools/Toolkit (3)

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Latent Errors

Approach to Improving Safety

•Quality Improvement Strategies (104)

•Legal and Policy Approaches (67)

•Error Reporting and Analysis (143)

•Communication Improvement (124)

•Human Factors Engineering (101)

•Teamwork (25)

•Specialization of Care (17)

•Logistical Approaches (53)

•Culture of Safety (70)

•Technologic Approaches (93)

•Education and Training (81)

Clinical Areas

•Allied Health Services (4)

•Medicine (315)

•Nursing (59)

•Pharmacy (61)

Target Audience

•Health Care Providers (312)

•Health Care Executives and Administrators (312)

•Non-Health Care Professionals (188)

•Patients (45)

Setting of Care

•Hospitals (304)

•Psychiatric Facilities (1)

•Residential Facilities (8)

•Ambulatory Care (46)

•Outpatient Surgery (4)

•Patient Transport (4)

1 - 20 of 444

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NEWSPAPER/MAGAZINE ARTICLE

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

Meisel Z. Slate. November 8, 2005.

NEWSPAPER/MAGAZINE ARTICLE

Our long journey towards a safety-minded just culture. Part II: where we're going.

ISMP Medication Safety Alert! Acute Care Edition. September 21, 2006;11:1-2.

NEWSPAPER/MAGAZINE ARTICLE

Inquiry into reporter's death finds multiple failures in care.

Stout D. New York Times. June 17, 2006;National desk:9.

COMMENTARY

Triage Time Bomb.

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

STUDY

Understanding diagnostic errors in medicine: a lesson from aviation.

Singh H, Petersen LA, Thomas EJ. Qual Saf Health Care. 2006;15:159-164.

COMMENTARY

Missed Appendicitis.

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

COMMENTARY

Lethal Vertigo.

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

COMMENTARY

Delay in Initiating Antibiotics Leads to Fatal Error.

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

STUDY

Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care.

Horwitz LI, Meredith T, Schuur JD, et al. Ann Emerg Med. 2009;53:701-710e1.

STUDY

Insufficient communication about medication use at the interface between hospital and primary care.

Glintborg B, Andersen SE, Dalhoff K. Qual Saf Health Care. 2007;16:34-39.

COMMENTARY

Right? Left? Neither!

Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.

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

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.

STUDY

Adverse events detected by clinical surveillance on an obstetric service.

Forster AJ, Fung I, Caughey S, et al. Obstet Gynecol. 2006;108:1073-1083.

COMMENTARY

Undiagnosed Vaginal Bleeding.

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

COMMENTARY

Discharge Fumbles.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals overhaul ERs to reduce mistakes.

Landro L. Wall Street Journal. May 10, 2011:D3.

STUDY

Applicability of Healthcare Failure Mode and Effects Analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments.

Linkin DR, Sausman C, Santos L, et al. Clin Infect Dis. 2005;41:1014-1019.

COMMENTARY

Lost in Transition

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

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