AHRQ Patient Safety Network

The Collection > Error Reporting

PATIENT SAFETY PRIMERS
Never Events
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Safety Target

•Device-related Complications (27)

•Diagnostic Errors (13)

•Identification Errors (23)

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

•Fatigue and Sleep Deprivation (6)

•Medication Safety (149)

•Medical Complications (67)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (61)

•Transfusion Complications (6)

•Psychological and Social Complications (31)

Origin/Sponsor

•Asia (15)

•Australia and New Zealand (28)

Resource Types

•Journal Article (372)

•Legislation/Regulation (8)

•Meeting/Conference (4)

•Newspaper/Magazine Article (55)

•Press Release/Announcement (7)

•Special or Theme Issue (8)

•Tools/Toolkit (10)

•Web Resource (18)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (192)

•Active Errors (63)

•Latent Errors (31)

•Near Miss (41)

Approach to Improving Safety
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Error Reporting

•Governmental Reporting (38)

•Institutional Reporting (53)

•Nongovernmental Reporting (6)

•Patient Disclosure (81)

•Patient Complaints (32)

•Never Events (31)

Clinical Areas

•Allied Health Services (4)

•Complementary and Alternative Medicine (2)

Target Audience

•Health Care Providers (328)

•Health Care Executives and Administrators (475)

•Non-Health Care Professionals (269)

•Patients (70)

Setting of Care

•Hospitals (300)

•Psychiatric Facilities (3)

•Residential Facilities (13)

•Ambulatory Care (48)

•Outpatient Surgery (11)

•Patient Transport (3)

1 - 20 of 557

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COMMENTARY

Communication with patients, suffering severe, avoidable harm as a result of treatment.

Cornwell J. Saferhealthcare. April 26, 2007.

STUDY

The limits of knowledge management for UK public services modernization: the case of patient safety and service quality.

Currie G, Waring J, Finn R. Public Admin. 2008;86:363-385.

REVIEW

Safety in obstetric critical care.

Scholefield H. Best Pract Res Clin Obstet Gynaecol. 2008;22:965-982.

COMMENTARY

Patient safety in cataract surgery.

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

COMMENTARY classic

Transforming healthcare: a safety imperative.

Leape L, Berwick D, Clancy C, et al; Lucian Leape Institute at the National Patient Safety Foundation. Qual Saf Health Care. 2009;18:424-428.

REVIEW

What have we learned about interventions to reduce medical errors?

Woodward HI, Mytton OT, Lemer C, et al. Annu Rev Public Health. 2010;31:479-497.

STUDY

Stories from the sharp end: case studies in safety improvement.

McCarthy D, Blumenthal D. Milbank Q. 2006;84:165-200.

COMMENTARY

In Conversation with...Sir Liam Donaldson, MD, MSc

AHRQ WebM&M [serial online]. May 2007.

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.

BOOK/REPORT

Quarterly National Reporting and Learning System Data Summary.

National Patient Safety Agency. London, UK: National Health Service.

MEETING/CONFERENCE PROCEEDINGS

Patient Safety 2006.

National Patient Safety Agency. February 1-2, 2006; International Convention Centre, Birmingham, UK.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2013.

STUDY

Implementation of medication error reporting through Med Safe Tool: the clinical pharmacists and the inpatient nursing staff collaborative approach.

Elnour AA, Ellahham NH, Al Qassas HI. J Patient Saf. 2007;3:177-183.

STUDY

Reporting of sentinel events in Swedish hospitals: a comparison of severe adverse events reported by patients and providers.

Öhrn A, Elfström J, Liedgren C, Rutberg H. Jt Comm J Qual Patient Saf. 2011;37:495-501.

COMMENTARY

Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality

Lindenauer P. AHRQ WebM&M [serial online]. November 2006.

STUDY

Hospital financial condition and the quality of patient care.

Bazzoli GJ, Chen HF, Zhao M, Lindrooth RC. Health Econ. 2008;17:977-995.

STUDY

National and local medication error reporting systems—a survey of practices in 16 countries.

Holmström AR, Airaksinen M, Weiss M, Wuliji T, Chan XH, Laaksonen R. J Patient Saf. 2012;8:165-176.

STUDY

Health care work environments, employee satisfaction, and patient safety: care provider perspectives.

Rathert C, May DR. Health Care Manage Rev. 2007;32:2-11.

BOOK/REPORT

Patient Safety in Canada: An Update.

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

BOOK/REPORT

Hospital Reporting Program.

Portland, OR: Oregon Patient Safety Commission.

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