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 (61)

•Diagnostic Errors (95)

•Identification Errors (56)

•Discontinuities, Gaps, and Hand-Off Problems (91)

•Fatigue and Sleep Deprivation (10)

•Medication Safety (498)

•Medical Complications (169)

•Nonsurgical Procedural Complications (34)

•Surgical Complications (255)

•Transfusion Complications (15)

•Psychological and Social Complications (65)

Origin/Sponsor

•Africa (3)

•Asia (26)

•Australia and New Zealand (37)

•Central and South America (3)

•Europe (295)

•North America (1194)

Resource Types

•Audiovisual (21)

•Award (3)

•Book/Report (124)

•Clinical Guideline (1)

•Journal Article (1181)

•Legislation/Regulation (6)

•Meeting/Conference (10)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (138)

•Press Release/Announcement (8)

•Special or Theme Issue (23)

•Tools/Toolkit (13)

•Web Resource (40)

Error Types

•Epidemiology of Errors and Adverse Events (657)

•Active Errors (215)

•Latent Errors (105)

•Near Miss (63)

Approach to Improving Safety
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Error Reporting and Analysis

•Error Reporting (639)

•Error Analysis (721)

•Patient Safety Indicators (85)

Clinical Areas

•Allied Health Services (3)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (1045)

•Health Care Executives and Administrators (1282)

•Non-Health Care Professionals (539)

•Patients (145)

Setting of Care

•Hospitals (899)

•Psychiatric Facilities (11)

•Residential Facilities (31)

•Ambulatory Care (130)

•Outpatient Surgery (24)

•Patient Transport (15)

1 - 20 of 1571

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STUDY

Quality and safety on an acute surgical ward: an exploratory cohort study of process and outcome.

Kreckler S, Catchpole KR, New SJ, Handa A, McCulloch PG. Ann Surg. 2009;250:1035-1040.

COMMENTARY

Learning from adverse events and near misses.

Greenberg CC. J Gastrointest Surg. 2008;13:3-5.

STUDY

Priority patient safety issues identified by perioperative nurses.

Steelman VM, Graling PR, Perkhounkova Y. AORN J. 2013;97:402-418.

COMMENTARY

What happens when things go wrong?

Brandom BW, Callahan P, Micalizzi DA. Paediatr Anaesth. 2011;21:730-736.

STUDY

Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study.

Gurses AP, Kim G, Martinez EA, et al. BMJ Qual Saf. 2012;21:810-818.

STUDY

Distractions and the anaesthetist: a qualitative study of context and direction of distraction.

Jothiraj H, Howland-Harris J, Evley R, Moppett IK. Br J Anaesth. 2013 Apr 16; [Epub ahead of print].

STUDY

Deconstructing intraoperative communication failures.

Hu YY, Arriaga AF, Peyre SE, Corso KA, Roth EM, Greenberg CC. J Surg Res. 2012;177:37-42.

STUDY

Wubben I, van Manen JG, van den Akker BJ, Vaartjes SR, van Harten WH. Qual Saf Health Care. 2010;19:e64.

STUDY

The influence of resident involvement on surgical outcomes.

Raval MV, Wang X, Cohen ME, et al. J Am Coll Surg. 2011;212:889-898.

STUDY

Pediatric antidepressant medication errors in a national error reporting database.

Rinke ML, Bundy DG, Shore AD, Colantuoni E, Morlock LL, Miller MR. J Dev Behav Pediatr. 2010;31:129-136.

STUDY

Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003.

Cook RI, Wreathall J, Smith A, et al. Transplantation. 2007;84:1602-1609.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.

Oakbrook Terrace, IL: The Joint Commission; January 2010.

REVIEW

Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations.

Miller MR, Robinson KA, Lubomski LH, Rinke ML, Pronovost PJ. Qual Saf Health Care. 2007;16:116-126.

STUDY

Quantitative analysis of adverse events in neurosurgery.

Houkin K, Baba T, Minamida Y, Nonaka T, Koyanagi I, Iiboshi S. Neurosurgery. 2009;65:587-594.

REVIEW

Failed spinal anaesthesia: mechanisms, management, and prevention.

Fettes PD, Jansson JR, Wildsmith JA. Br J Anaesth. 2009;102:739-748.

STUDY

Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.

Steinberger DM, Douglas SV, Kirschbaum MS. Prog Transplant. 2009;19:208-215.

STUDY

Cranshaw J, Gupta KJ, Cook TM. Anaesthesia. 2009;64:1317-1323.

STUDY

A comparison of voluntarily reported medication errors in intensive care and general care units.

Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.

STUDY

Barriers to adverse event and error reporting in anesthesia.

Heard GC, Sanderson PM, Thomas RD. Anesth Analg. 2012;114:604-614.

SPECIAL OR THEME ISSUE

Identification and Prevention of Common Adverse Drug Events in the Intensive Care Unit.

Papadopoulos J, Kane-Gill SL, Cooper B, eds. Crit Care Med. 2010;38:(suppl 6):S83-S264.

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