AHRQ Patient Safety Network

The Collection > Error Reporting

PATIENT SAFETY PRIMERS
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Safety Target

•Device-related Complications (18)

•Diagnostic Errors (4)

•Identification Errors (8)

•Discontinuities, Gaps, and Hand-Off Problems (10)

•Fatigue and Sleep Deprivation (1)

•Medication Safety (83)

•Medical Complications (17)

•Nonsurgical Procedural Complications (5)

•Surgical Complications (24)

•Transfusion Complications (1)

•Psychological and Social Complications (5)

Origin/Sponsor

•Africa (1)

•Asia (6)

•Australia and New Zealand (30)

Resource Types

•Journal Article (191)

•Legislation/Regulation (2)

•Meeting/Conference (1)

•Newspaper/Magazine Article (16)

•Press Release/Announcement (2)

•Special or Theme Issue (2)

•Tools/Toolkit (2)

•Web Resource (8)

Error Types

•Epidemiology of Errors and Adverse Events (65)

•Active Errors (36)

•Latent Errors (14)

•Near Miss (16)

Approach to Improving Safety
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Error Reporting

•Governmental Reporting (3)

•Institutional Reporting (17)

•Nongovernmental Reporting (2)

•Patient Disclosure (9)

•Patient Complaints (5)

•Never Events (2)

Clinical Areas

•Allied Health Services (4)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (133)

•Health Care Executives and Administrators (222)

•Non-Health Care Professionals (96)

•Patients (14)

Setting of Care

•Hospitals (127)

•Psychiatric Facilities (1)

•Residential Facilities (5)

•Ambulatory Care (17)

•Outpatient Surgery (5)

•Patient Transport (6)

1 - 20 of 235

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STUDY

Impact of a comprehensive safety initiative on patient-controlled analgesia errors.

Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.

NEWSPAPER/MAGAZINE ARTICLE

Double key bounce and double keying errors.

ISMP Medication Safety Alert! Acute Care Edition. January 12, 2006;11:1-2.

STUDY

Review of the Australian Incident Monitoring System.

Spigelman AD, Swan J. ANZ J Surg. 2005;75:657-661.

COMMENTARY

Impatient Inpatient Dosing

White RH. AHRQ WebM&M [serial online]. July/August 2005.

NEWSPAPER/MAGAZINE ARTICLE

Doctors see flaw in device recalls.

Kerber R. The Boston Globe. June 23, 2005;Business section:E1.

STUDY

Barriers to adverse event and error reporting in anesthesia.

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

STUDY

Assessment of the global trigger tool to measure, monitor and evaluate patient safety in cancer patients: reliability concerns are raised.

Mattsson TO, Knudsen JL, Lauritsen J, Brixen K, Herrstedt J. BMJ Qual Saf. 2013;22:571-579.

COMMENTARY classic

Counterheroism, common knowledge, and ergonomics: concepts from aviation that could improve patient safety.

Lewis GH, Vaithianathan R, Hockey PM, Hirst G, Bagian JP. Milbank Q. 2011;89:4-38.

STUDY

Preventable morbidity at a mature trauma center.

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

STUDY

Adverse events and comparison of systematic and voluntary reporting from a paediatric intensive care unit.

Silas R, Tibballs J. Qual Saf Health Care. 2010;19:568-571.

STUDY

Computer based medication error reporting: insights and implications.

Miller MR, Clark JS, Lehmann CU. Qual Saf Health Care. 2006;15:208-213.

STUDY

Certain uncertainties: modes of patient safety in healthcare.

Jerak-Zuiderent S. Soc Stud Sci. 2012;42:732-752.

REVIEW

Medical error and human factors engineering: where are we now?

Gawron VJ, Drury CG, Fairbanks RJ, Berger RC. Am J Med Qual. 2006;21:57-67.

REVIEW

Prevalence and nature of medication administration errors in health care settings: a systematic review of direct observational evidence.

Keers RN, Williams SD, Cooke J, Ashcroft DM. Ann Pharmacother. 2013;47:237-256.

COMMENTARY

Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience

Conway JB, Weingart SN. AHRQ WebM&M [serial online]. May 2005.

STUDY

Patient notification for bloodborne pathogen testing due to unsafe injection practices in the US health care settings, 2001–2011.

Guh AY, Thompson ND, Schaefer MK, Patel PR, Perz JF. Med Care. 2012;50:785-791.

COMMENTARY

Medication errors: immunisation.

Bird S. Aust Fam Physician. 2006;35:735-737.

COMMENTARY

The nuclear power industry as an alternative analogy for safety in anaesthesia and a novel approach for the conceptualisation of safety goals.

Webster CS. Anaesthesia. 2005;60:1115-1122.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010:45;352-355.

COMMENTARY

Using portable digital technology for clinical care and critical incidents: a new model.

Bolsin SN, Faunce T, Colson M. Aust Health Rev. 2005;29:297-305.

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