AHRQ Patient Safety Network

The Collection > Error Reporting and Analysis

PATIENT SAFETY PRIMERS
Detection of Safety Hazards

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Safety Target

•Device-related Complications (35)

•Diagnostic Errors (73)

•Identification Errors (19)

•Discontinuities, Gaps, and Hand-Off Problems (52)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (230)

•Medical Complications (67)

•Nonsurgical Procedural Complications (13)

•Surgical Complications (120)

•Transfusion Complications (8)

•Psychological and Social Complications (37)

Origin/Sponsor

•Africa (1)

•Asia (11)

•Australia and New Zealand (13)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (619)

•Legislation/Regulation (2)

•Meeting/Conference (3)

•Newspaper/Magazine Article (84)

•Press Release/Announcement (3)

•Special or Theme Issue (11)

•Tools/Toolkit (4)

•Web Resource (9)

Error Types

•Epidemiology of Errors and Adverse Events (481)

•Active Errors (100)

•Latent Errors (36)

•Near Miss (31)

Approach to Improving Safety
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Error Reporting and Analysis

•Error Reporting (255)

•Error Analysis (354)

•Patient Safety Indicators (38)

Clinical Areas

•Medicine (566)

•Nursing (34)

•Pharmacy (82)

Target Audience

•Health Care Providers (546)

•Health Care Executives and Administrators (581)

•Non-Health Care Professionals (217)

•Patients (56)

Setting of Care

•Hospitals (455)

•Psychiatric Facilities (6)

•Residential Facilities (17)

•Ambulatory Care (77)

•Outpatient Surgery (14)

•Patient Transport (6)

1 - 20 of 784

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STUDY

Direct observation approach for detecting medication errors and adverse drug events in a pediatric intensive care unit.

Buckley MS, Erstad BL, Kopp BJ, Theodorou AA, Priestley G. Pediatr Crit Care Med. 2007;8:145-152.

STUDY

Management of the difficult airway: a closed claims analysis.

Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Anesthesiology. 2005;103:33-39.

STUDY

Cognitive errors detected in anaesthesiology: a literature review and pilot study.

Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Br J Anaesth. 2012;108:229-235.

STUDY

The association between frequency of self-reported medical errors and anesthesia trainee supervision: a survey of United States anesthesiology residents-in-training.

De Oliveira GS Jr, Rahmani R, Fitzgerald PC, Chang R, McCarthy RJ. Anesth Analg. 2013;116:892-897.

STUDY

A facilitated survey instrument captures significantly more anesthesia events than does traditional voluntary event reporting.

Oken A, Rasmussen MD, Slagle JM, et al. Anesthesiology. 2007;107:909-922.

NEWSPAPER/MAGAZINE ARTICLE

Medication administration in anesthesia: time for a paradigm shift.

Stabile M, Webster CS, Merry AF. APSF Newsletter. Fall 2007;22:44-47.

COMMENTARY classic

Epidemiology of medical error.

Weingart SN, Wilson RM, Gibberd RW, Harrison B. BMJ. 2000;320:774-777.

STUDY

Adverse event reporting: lessons learned from 4 years of Florida office data.

Coldiron B, Fisher AH, Adelman E, et al. Dermatol Surg. 2005;31(pt 1):1079-1092; discussion 1093.

BOOK/REPORT

Utah Tenth Anniversary (2001–2011) Patient Safety Report: Identifying Opportunities for Improvement.

Salt Lake City, UT: Utah Department of Health, HealthInsight, Utah Hospital Association; 2012.

STUDY

The emotional impact of medical errors on practicing physicians in the United States and Canada.

Waterman AD, Garbutt J, Hazel E, et al. Jt Comm J Qual Patient Saf. 2007;33:467-476.

STUDY

Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors.

Wagar EA, Tamashiro L, Yasin B, Hilborne L, Bruckner DA. Arch Pathol Lab Med. 2006;130:1662-1668.

STUDY

CT for suspected appendicitis in children: an analysis of diagnostic errors.

Taylor GA, Callahan MJ, Rodriguez D, Smink DS. Pediatr Radiol. 2006;36:331-337.

STUDY

Studying critical values: adverse event identification following a critical laboratory values study at the Ohio State University Medical Center.

Jenkins JJ, Mac Crawford J, Bissell MG. Am J Clin Pathol. 2007;128:604-609.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:556-557.

STUDY

Burnout and satisfaction with work-life balance among US physicians relative to the general US population.

Shanafelt TD, Boone S, Tan L, et al. Arch Intern Med. 2012;172:1377-1385.

STUDY

Medication errors in the outpatient setting: classification and root cause analysis.

Friedman AL, Geoghegan SR, Sowers NM, Kulkarni S, Formica RN Jr. Arch Surg. 2007;142:278-283.

STUDY

Medication errors during medical emergencies in a large, tertiary care, academic medical center.

Gokhman R, Seybert AL, Phrampus P, Darby J, Kane-Gill SL. Resuscitation. 2012;83:482-487.

STUDY

Effectiveness of a community collaborative for eliminating the use of high-risk abbreviations written by physicians.

Leonhardt KK, Botticelli J. J Patient Saf. 2006;2:147-153.

STUDY

Cardiac surgery errors: results from the UK National Reporting and Learning System.

Martinez EA, Shore A, Colantuoni E, et al. Int J Qual Health Care. 2011;23:151-158.

STUDY

Preventable morbidity at a mature trauma center.

Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.

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