AHRQ Patient Safety Network

The Collection > Error Reporting

PATIENT SAFETY PRIMERS
Never Events
Systems Approach

Narrow By

clear selections

Safety Target

•Device-related Complications (26)

•Diagnostic Errors (23)

•Identification Errors (26)

•Discontinuities, Gaps, and Hand-Off Problems (30)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (167)

•Medical Complications (73)

•Nonsurgical Procedural Complications (12)

•Surgical Complications (68)

•Transfusion Complications (7)

•Psychological and Social Complications (38)

Origin/Sponsor

•Africa (1)

•Asia (18)

•Australia and New Zealand (30)

Resource Types

•Journal Article (413)

•Legislation/Regulation (12)

•Meeting/Conference (4)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (78)

•Press Release/Announcement (10)

•Special or Theme Issue (9)

•Tools/Toolkit (12)

•Web Resource (27)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (153)

•Active Errors (92)

•Latent Errors (47)

•Near Miss (29)

Approach to Improving Safety
< All

Error Reporting

•Governmental Reporting (51)

•Institutional Reporting (69)

•Nongovernmental Reporting (13)

•Patient Disclosure (110)

•Patient Complaints (40)

•Never Events (43)

Clinical Areas

•Allied Health Services (4)

•Complementary and Alternative Medicine (2)

Target Audience

•Health Care Providers (418)

•Health Care Executives and Administrators (525)

•Non-Health Care Professionals (261)

•Patients (92)

Setting of Care

•Hospitals (402)

•Psychiatric Facilities (4)

•Residential Facilities (12)

•Ambulatory Care (48)

•Outpatient Surgery (12)

•Patient Transport (4)

1 - 20 of 652

Show ExcerptDon't Show Excerpt

dropdown

COMMENTARY

Do Not Disturb!

Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2013.

BOOK/REPORT

Patient Safety in Canada: An Update.

Ottawa, ON, Canada: Canadian Institute for Health Information; August 14, 2007.

STUDY

Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant.

Levtzion-Korach O, Frankel A, Alcalai H, et al. Jt Comm J Qual Patient Saf. 2010;36:402-410.

REVIEW

Accountability for medical error: moving beyond blame to advocacy.

Bell SK, Delbanco T, Anderson-Shaw L, McDonald TB, Gallagher TH. Chest. 2011;140:519-526.

BOOK/REPORT

Hospital Performance Report.

Trenton, NJ: New Jersey Department of Health and Senior Services; March 2012.

STUDY

Possible solutions for barriers in incident reporting by residents.

Martowirono K, Jansma JD, Van Luijk SJ, Wagner C, Bijnen AB. J Eval Clin Pract. 2012;18:76-81.

GOVERNMENT RESOURCE classic

Partnership for Patients.

Washington, DC: US Department of Health and Human Services.

STUDY

Association between hospital-reported Leapfrog Safe Practices scores and inpatient mortality.

Kernisan LP, Lee SJ, Boscardin WJ, Landefeld CS, Dudley RA. JAMA. 2009;301:1341-1348.

BOOK/REPORT

2009 Utah Sentinel Events Data Report.

Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.

STUDY

Measurement for improvement: a survey of current practice in Australian public hospitals.

Brand CA, Tropea J, Ibrahim JE, et al. Med J Aust. 2008;189:35-40.

AUDIOVISUAL

Good News: How Hospitals Heal Themselves [documentary].

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

NEWSPAPER/MAGAZINE ARTICLE

When errors occur.

Wetzel TG. Hosp Health Netw. October 2010.

STUDY

Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents.

Davies EC, Green CF, Mottram DR, Pirmohamed M. Br J Clin Pharmacol. 2010;70:102-108.

STUDY

The relationship between organizational leadership for safety and learning from patient safety events.

Ginsburg LR, Chuang YT, Berta WB, et al. Health Serv Res. 2010;45:607-632.

BOOK/REPORT

Hospital Reporting Program.

Portland, OR: Oregon Patient Safety Commission.

STUDY

'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured.

Classen DC, Resar R, Griffin F, et al. Health Aff (Millwood). 2011;30:581-589.

BOOK/REPORT

The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System.

Thompson WC Jr. New York, NY: Office of the New York City Comptroller, Office of Policy Management; 2009.

BOOK/REPORT

Consumer Guide to Adverse Health Events.

St. Paul, MN: Minnesota Department of Health; January 2009.

NEWSPAPER/MAGAZINE ARTICLE

Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety.

Luther K, Resar RK. Healthc Exec. Jan/Feb 2013;28:84-87.

1 2 3 4 5 6 7 8 9 10 11 Next >