AHRQ Patient Safety Network

The Collection > Error Reporting

PATIENT SAFETY PRIMERS
Never Events
Systems Approach

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Safety Target

•Device-related Complications (28)

•Diagnostic Errors (20)

•Identification Errors (34)

•Discontinuities, Gaps, and Hand-Off Problems (28)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (186)

•Medical Complications (81)

•Nonsurgical Procedural Complications (12)

•Surgical Complications (87)

•Transfusion Complications (8)

•Psychological and Social Complications (36)

Origin/Sponsor

•Asia (8)

•Australia and New Zealand (22)

Resource Types

•Journal Article (415)

•Legislation/Regulation (11)

•Meeting/Conference (3)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (100)

•Press Release/Announcement (9)

•Special or Theme Issue (7)

•Tools/Toolkit (10)

•Web Resource (24)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (219)

•Active Errors (83)

•Latent Errors (26)

•Near Miss (33)

Approach to Improving Safety
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Error Reporting

•Governmental Reporting (45)

•Institutional Reporting (61)

•Nongovernmental Reporting (10)

•Patient Disclosure (97)

•Patient Complaints (22)

•Never Events (64)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (394)

•Health Care Executives and Administrators (530)

•Non-Health Care Professionals (280)

•Patients (97)

Setting of Care

•Hospitals (354)

•Psychiatric Facilities (2)

•Residential Facilities (18)

•Ambulatory Care (47)

•Outpatient Surgery (16)

•Patient Transport (8)

1 - 20 of 657

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BOOK/REPORT

Adverse Health Events in Minnesota: Ninth Annual Public Report.

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

COMMENTARY

Path to safety: benefits of the 2005 Patient Safety and Quality Improvement Act.

McBride D, Greening A, Redmond D. Healthc Financ Manage. June 2006;60:84-88.

NEWSPAPER/MAGAZINE ARTICLE

Plan would compile, analyze medical errors.

Gaul GM. The Washington Post. July 29, 2005:A06.

BOOK/REPORT

Adverse Events in Hospitals: Overview of Key Issues.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470.

STUDY

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

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

STUDY

Slow progress on meeting hospital safety standards: learning from the Leapfrog Group's efforts.

Moran J, Scanlon D. Health Aff (Millwood). 2013;32:27-35.

STUDY

The long road to patient safety: a status report on patient safety systems.

Longo DR, Hewett JE, Ge B, Schubert S. JAMA. 2005;294:2858-2865.

REVIEW

Journal reporting of medical errors: the wisdom of Solomon, the bravery of Achilles, and the foolishness of Pan.

Murphy JG, Stee L, McEvoy MT, Oshiro J. Chest. 2007;131:890-896.

COMMENTARY

Making the Patient Safety and Quality Improvement Act of 2005 work.

Vemula R, Assaf RR, Al-Assaf AF. J Healthc Qual. 2007;29:6-10.

NEWSPAPER/MAGAZINE ARTICLE

No pay for "never event" errors becoming standard.

O'Reilly KB. American Medical News. January 7, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Preventing fatal errors.

Bailey B, Sevrens Lyons J. The Mercury News. November 27, 2005.

NEWSPAPER/MAGAZINE ARTICLE

NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action.

DerGurahian J. Mod Healthc. June 16, 2008;38:6.

COMMENTARY

The Patient Safety and Quality Improvement Act of 2005: provisions and potential opportunities.

Liang BA, Riley W, Rutherford W, Hamman W. Am J Med Qual. 2007;22:8-12.

BOOK/REPORT classic

The Economic Measurement of Medical Errors.

Shreve J, van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E. Schaumburg, IL: The Society of Actuaries; 2010.

BOOK/REPORT

Hospital Reporting Program.

Portland, OR: Oregon Patient Safety Commission.

COMMENTARY

Drill down with root cause analysis.

McDonald A, Leyhane T. Nurs Manage. 2005;36:26-32.

MULTI-USE WEBSITE

HAC Posting on Hospital Compare.

Centers for Medicare & Medicaid Services.

STUDY

Preventable morbidity at a mature trauma center.

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

COMMENTARY

Developing a medication patient safety program — infrastructure and strategy.

Mark SM, Weber RJ. Hosp Pharm. 2007;42:149-156.

STUDY

Venous thromboembolism after trauma: a never event?

Thorson CM, Ryan ML, Van Haren RM, et al. Crit Care Med. 2012;40:2967-2973.

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