AHRQ Patient Safety Network

The Collection > Error Reporting

PATIENT SAFETY PRIMERS
Never Events
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Safety Target

•Device-related Complications (32)

•Diagnostic Errors (24)

•Identification Errors (34)

•Discontinuities, Gaps, and Hand-Off Problems (31)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (213)

•Medical Complications (79)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (85)

•Transfusion Complications (7)

•Psychological and Social Complications (53)

Origin/Sponsor

•Africa (1)

•Asia (19)

•Australia and New Zealand (27)

Resource Types

•Journal Article (563)

•Legislation/Regulation (7)

•Meeting/Conference (1)

•Newspaper/Magazine Article (114)

•Press Release/Announcement (8)

•Special or Theme Issue (14)

•Tools/Toolkit (12)

•Web Resource (22)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (190)

•Active Errors (123)

•Latent Errors (39)

•Near Miss (44)

Approach to Improving Safety
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Error Reporting

•Governmental Reporting (29)

•Institutional Reporting (102)

•Nongovernmental Reporting (19)

•Patient Disclosure (200)

•Patient Complaints (41)

•Never Events (44)

Clinical Areas

•Allied Health Services (4)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (515)

•Health Care Executives and Administrators (635)

•Non-Health Care Professionals (287)

•Patients (101)

Setting of Care

•Hospitals (449)

•Psychiatric Facilities (2)

•Residential Facilities (21)

•Ambulatory Care (57)

•Outpatient Surgery (14)

•Patient Transport (8)

1 - 20 of 818

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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.

NEWSPAPER/MAGAZINE ARTICLE

Dose of technology helps Shands at UF avoid drug errors.

Chun D. Gainsville Sun. August 21, 2006.

STUDY

Nurses' perceptions of causes of medication errors and barriers to reporting.

Ulanimo VM, O'Leary-Kelley C, Connolly PM. J Nurs Care Qual. 2007;22:28-33.

STUDY

Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medical directors' attitudes and experiences.

Dintzis SM, Stetsenko GY, Sitlani CM, Gronowski AM, Astion ML, Gallagher TH. Am J Clin Pathol. 2011;135:760-765.

STUDY

Attitudes and barriers to incident reporting: a collaborative hospital study.

Evans SM, Berry JG, Smith BJ, et al. Qual Saf Health Care. 2006;15:39-43.

STUDY

Patient-reported service quality on a medicine unit.

Weingart SN, Pagovich O, Sands DZ, et al. Int J Qual Health Care. 2005;18:95-101.

STUDY

What is the measure of a safe hospital? Medication errors missed by risk management, clinical staff, and surveyors.

Grasso BC, Rothschild JM, Jordan CW, Jayaram G. J Psychiatr Pract. 2005;11:268-273.

COMMENTARY

A multifaceted approach to improve patient safety, prevent medical errors and resolve the professional liability crisis.

Weinstein L. Am J Obstet Gynecol. 2006;194:1160-1165; discussion 1165-1167.

STUDY

A facilitated survey instrument captures significantly more anesthesia events than does traditional voluntary event reporting.

Oken A, Rasmussen MD, Slagle JM, et al. Anesthesiology. 2007;107:909-922.

NEWSPAPER/MAGAZINE ARTICLE

Our long journey towards a safety-minded just culture. Part I: Where we've been.

ISMP Medication Safety Alert! Acute Care Edition. September 7, 2006;11:1-3.

COMMENTARY

Antecedents of willingness to report medical treatment errors in health care organizations: a multilevel theoretical framework.

Naveh E, Katz-Navon T. Health Care Manage Rev. 2013 Feb 1; [Epub ahead of print].

COMMENTARY

A nurse-driven system for improving patient quality outcomes.

Johnson K, Hallsey D, Meredith RL, Warden E. J Nurs Care Qual. 2006;21:168-175.

STUDY

Residents report on adverse events and their causes.

Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS. Arch Intern Med. 2005;165:2607-2613.

COMMENTARY

In Conversation with...Allan Frankel, MD

AHRQ WebM&M [serial online]. July 2006.

STUDY

Improving self-reporting of adverse drug events in a West Virginia hospital.

Schade CP, Hannah K, Ruddick P, Starling C, Brehm J. Am J Med Qual. 2006;21:335-341.

STUDY

Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors.

Wagar EA, Tamashiro L, Yasin B, Hilborne L, Bruckner DA. Arch Pathol Lab Med. 2006;130:1662-1668.

NEWSPAPER/MAGAZINE ARTICLE

Medical errors still claiming many lives.

Weise E. USA Today. May 18, 2005.

STUDY

Designing and implementing a comprehensive quality and patient safety management model: a paradigm for perioperative improvement.

Herzer KR, Mark LJ, Michelson JD, Saletnik LA, Lundquist CA. J Patient Saf. 2008;4:84-92.

STUDY

Disclosure, apology, and offer programs: stakeholders' views of barriers to and strategies for broad implementation.

Bell SK, Smulowitz PB, Woodward AC, et al. Milbank Q. 2012;90:682-705.

MULTI-USE WEBSITE

California Hospital Patient Safety Organization.

1215 K Street, Suite 800, Sacramento, CA 95814.

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