AHRQ Patient Safety Network

The Collection > Latent Errors

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•Device-related Complications (36)

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•Discontinuities, Gaps, and Hand-Off Problems (87)

•Fatigue and Sleep Deprivation (10)

•Medication Safety (149)

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Latent Errors

Approach to Improving Safety

•Quality Improvement Strategies (104)

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Target Audience

•Health Care Providers (326)

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•Non-Health Care Professionals (203)

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Setting of Care

•Hospitals (314)

•Psychiatric Facilities (2)

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1 - 20 of 462

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AUDIOVISUAL

Good News: How Hospitals Heal Themselves [documentary].

Washington, DC: CCM, Inc.; 2006. Crawford-Mason C (producer), Dobyns L (reporter); Management Wisdom Video Series.

BOOK/REPORT

Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care.

Roundtable on Joy and Meaning in Work and Workforce Safety, The Lucian Leape Institute. Boston, MA: National Patient Safety Foundation; 2013.

NEWSPAPER/MAGAZINE ARTICLE

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

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

AUDIOVISUAL

Chasing Zero: Winning the War on Healthcare Harm.

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

COMMENTARY

Patient safety in women's health care: a framework for progress.

Gluck PA. Best Pract Res Clin Obstet Gynaecol. 2007;21:525-36.

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.

COMMENTARY

Frontline hospital workers and the worker safety/patient safety nexus.

Sokas R, Braun B, Chenven L, et al. Jt Comm J Qual Patient Saf. 2013;39:185-192.

BOOK/REPORT

Organisational Failure: An Exploratory Study in the Steel Industry and Medical Domain.

van Vuuren W. [dissertation]. Eindhoven, The Netherlands: Eindhoven University of Technology; 1998.

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.

SPECIAL OR THEME ISSUE

Front-Line Ownership: Generating a Cure Mindset for Patient Safety.

Kitts J, ed. Healthcare Papers. 2013;13:1-82.

NEWSPAPER/MAGAZINE ARTICLE

Raising the index of suspicion: red flags that represent credible threats to patient safety.

ISMP Medication Safety Alert! Acute Care Edition. July 26, 2012;17:1-3.

COMMENTARY

Development of an expert system for classification of medical errors.

Kopec D, Levy K, Kabir M, Reinharth D, Shagas G. Stud Health Technol Inform. 2005;114:110-116.

NEWSPAPER/MAGAZINE ARTICLE

Fatal drug mix-up exposes hospital flaws.

Davies T. Washington Post. September 22, 2006.

STUDY

Application of the human factors analysis and classification system methodology to the cardiovascular surgery operating room.

ElBardissi AW, Wiegmann DA, Dearani JA, Daly RC, Sundt TM 3rd. Ann Thorac Surg. 2007;83:1412-1418; discussion 1418-1419.

NEWSPAPER/MAGAZINE ARTICLE

A long way to go.

DerGurahian J. Mod Healthc. December 7, 2009.

PRESS RELEASE/ANNOUNCEMENT

Hydrocodone bitartrate and acetaminophen tablets, phenobarbital tablets by Qualitest: recall—incorrect package labeling.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 7, 2011.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals target risks of color wristbands.

Landro L. Wall Street Journal. April 4, 2007:D5.

STUDY

Patient misidentification in Papanicolaou tests: a systems-based approach to reducing errors.

Meyer E, Underwood RS, Padmanabhan V. Arch Pathol Lab Med. 2009;133:1297-1300.

BOOK/REPORT

Fluorouracil Incident Root Cause Analysis Report.

Toronto, ON, Canada: Institute for Safe Medication Practices Canada. May 8, 2007.

REVIEW

Hospital do-not-resuscitate orders: why they have failed and how to fix them.

Yuen JK, Reid MC, Fetters MD. J Gen Intern Med. 2011;26:791-797.

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