AHRQ Patient Safety Network

The Collection > Error Reporting

PATIENT SAFETY PRIMERS
Never Events
Systems Approach

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Safety Target

•Device-related Complications (21)

•Diagnostic Errors (19)

•Identification Errors (31)

•Discontinuities, Gaps, and Hand-Off Problems (23)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (150)

•Medical Complications (49)

•Nonsurgical Procedural Complications (12)

•Surgical Complications (97)

•Transfusion Complications (6)

•Psychological and Social Complications (20)

Origin/Sponsor

•Asia (9)

•Australia and New Zealand (22)

Resource Types

•Journal Article (333)

•Legislation/Regulation (2)

•Meeting/Conference (3)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (42)

•Press Release/Announcement (5)

•Special or Theme Issue (8)

•Tools/Toolkit (9)

•Web Resource (21)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (126)

•Active Errors (83)

•Latent Errors (30)

•Near Miss (25)

Approach to Improving Safety
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Error Reporting

•Governmental Reporting (16)

•Institutional Reporting (34)

•Nongovernmental Reporting (7)

•Patient Disclosure (64)

•Patient Complaints (9)

•Never Events (28)

Clinical Areas

•Allied Health Services (4)

•Complementary and Alternative Medicine (2)

Target Audience

•Health Care Providers (332)

•Health Care Executives and Administrators (376)

•Non-Health Care Professionals (174)

•Patients (56)

Setting of Care

•Hospitals (251)

•Psychiatric Facilities (2)

•Residential Facilities (11)

•Ambulatory Care (38)

•Outpatient Surgery (13)

•Patient Transport (5)

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STUDY

Incorrect surgical procedures within and outside of the operating room.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

STUDY

Promoting patient safety through prospective risk identification: example from peri-operative care.

Smith A, Boult M, Woods I, Johnson S. Qual Saf Health Care. 2010;19:69-73.

STUDY

Continuous monitoring of adverse events: influence on the quality of care and the incidence of errors in general surgery.

Rebasa P, Mora L, Luna A, Montmany S, Vallverdú H, Navarro S. World J Surg. 2009;33:191-198.

REVIEW

Detecting adverse events in dermatologic surgery.

Pinney D, Pearce DJ, Feldman SR. Dermatol Surg. 2010;36:8-14.

STUDY

Barriers to adverse event and error reporting in anesthesia.

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

COMMENTARY classic

Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand.

Ring DC, Herndon JH, Meyer GS. N Engl J Med. 2010;363:1950-1957.

STUDY

Factors influencing incident reporting in surgical care.

Kreckler S, Catchpole K, McCulloch P, Handa A. Qual Saf Health Care. 2009;18:116-120.

STUDY

Integrating incident reporting into an electronic patient record system.

Haller G, Myles PS, Stoelwinder J, Langley M, Anderson H, McNeil J. J Am Med Inform Assoc. 2007;14:175-181.

STUDY

Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes.

Antonacci AC, Lam S, Lavarias V, Homel P, Eavey RD. Arch Surg. 2008;143:1192-1197.

NEWSPAPER/MAGAZINE ARTICLE

Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.

Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.

STUDY

A comprehensive obstetrics patient safety program improves safety climate and culture.

Pettker CM, Thung SF, Raab CA, et al. Am J Obstet Gynecol. 2011;204:216.e1-e6.

STUDY

Patient characteristics and the occurrence of never events.

Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.

COMMENTARY

The Other Side.

Vincent C. AHRQ WebM&M [serial online]. October 2003.

STUDY

Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors.

Panesar SS, Carson-Stevens A, Salvilla SA, Patel B, Mirza SB, Mann B. Drug Healthc Patient Saf. 2013;5:57-65.

STUDY

Preventable morbidity at a mature trauma center.

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

STUDY

Potential errors and their prevention in operating room teamwork as experienced by Finnish, British and American nurses.

Silén-Lipponen M, Tossavainen K, Turunen H, Smith A. Int J Nurs Pract. 2005;11:21-32.

STUDY

Towards safer neonatal transfer: the importance of critical incident review.

Moss SJ, Embleton ND, Fenton AC. Arch Dis Child. 2005;90:729-732.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2012.

COMMENTARY

Patient safety in cataract surgery.

Kelly SP, Astbury NJ. Eye. 2006;20:275-282.

STUDY

Hospital process compliance and surgical outcomes in Medicare beneficiaries.

Nicholas LH, Osborne NH, Birkmeyer JD, Dimick JB. Arch Surg. 2010;145:999-1004.

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