AHRQ Patient Safety Network

The Collection > Error Reporting

PATIENT SAFETY PRIMERS
Never Events
Systems Approach

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Safety Target

•Device-related Complications (26)

•Diagnostic Errors (23)

•Identification Errors (33)

•Discontinuities, Gaps, and Hand-Off Problems (26)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (158)

•Medical Complications (47)

•Nonsurgical Procedural Complications (10)

•Surgical Complications (68)

•Transfusion Complications (4)

•Psychological and Social Complications (24)

Origin/Sponsor

•Asia (13)

•Australia and New Zealand (17)

Resource Types

•Journal Article (320)

•Legislation/Regulation (3)

•Meeting/Conference (3)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (54)

•Press Release/Announcement (5)

•Special or Theme Issue (4)

•Tools/Toolkit (8)

•Web Resource (18)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (181)

•Active Errors (113)

•Latent Errors (45)

•Near Miss (34)

Approach to Improving Safety
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Error Reporting

•Governmental Reporting (19)

•Institutional Reporting (36)

•Nongovernmental Reporting (9)

•Patient Disclosure (56)

•Patient Complaints (13)

•Never Events (25)

Clinical Areas

•Allied Health Services (4)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (352)

•Health Care Executives and Administrators (356)

•Non-Health Care Professionals (165)

•Patients (68)

Setting of Care

•Hospitals (256)

•Psychiatric Facilities (3)

•Residential Facilities (13)

•Ambulatory Care (46)

•Outpatient Surgery (13)

•Patient Transport (6)

1 - 20 of 453

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COMMENTARY

Failure to Report

Spath PL. AHRQ WebM&M [serial online]. March 2007.

STUDY

Error tracking in a clinical biochemistry laboratory.

Szecsi PB, Ødum L. Clin Chem Lab Med. 2009;47:1253-1257.

STUDY

Wrong-site sinus surgery in otolaryngology.

Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2013.

STUDY

Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.

Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.

COMMENTARY

Internally-developed online adverse drug reaction and medication error reporting systems.

Smith KM, Trapskin PJ, Empey PE, Hecht KA, Armitstead JA. Hosp Pharm. 2006;41:428-436.

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

Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?

Seiden SC, Barach P. Arch Surg. 2006;141:931-939.

BOOK/REPORT

Adverse Health Events in Minnesota: Ninth Annual Public Report.

St. Paul, MN: Minnesota Department of Health; January 2013.

STUDY

The incidence and nature of prescribing and medication administration errors in paediatric inpatients.

Ghaleb MA, Barber N, Franklin BD, Wong ICK. Arch Dis Child. 2010;95:113-118.

STUDY

Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.

Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.

FACT SHEET/FAQS

Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.

Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:405-406.

COMMENTARY

Check the Wristband.

Rosenthal MM. AHRQ WebM&M [serial online]. July 2003.

COMMENTARY

The Role of the Patient in Improving Patient Safety

Gibson R. AHRQ WebM&M [serial online]. March 2007.

BOOK/REPORT

Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety.

Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.

COMMENTARY

Do Not Disturb!

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

COMMENTARY

Shake Well.

Flynn EA. AHRQ WebM&M [serial online]. September 2003.

NEWSPAPER/MAGAZINE ARTICLE

Diagnostic error in acute care.

PA-PSRS Patient Saf Advis. 2010;7:76-86.

REVIEW

Monitoring for medication errors in outpatient settings.

Balkrishnan R, Foss CE, Pawaskar M, Uhas AA, Feldman SR. J Dermatolog Treat. 2009;20:229-232.

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