AHRQ Patient Safety Network

The Collection > Error Reporting

PATIENT SAFETY PRIMERS
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Safety Target

•Device-related Complications (19)

•Diagnostic Errors (16)

•Identification Errors (20)

•Discontinuities, Gaps, and Hand-Off Problems (25)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (135)

•Medical Complications (54)

•Nonsurgical Procedural Complications (10)

•Surgical Complications (48)

•Transfusion Complications (6)

•Psychological and Social Complications (17)

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•Africa (1)

•Asia (17)

•Australia and New Zealand (25)

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•Journal Article (347)

•Legislation/Regulation (3)

•Meeting/Conference (1)

•Newspaper/Magazine Article (32)

•Press Release/Announcement (1)

•Special or Theme Issue (4)

•Tools/Toolkit (4)

•Web Resource (15)

Error Types

•Epidemiology of Errors and Adverse Events (229)

•Active Errors (59)

•Latent Errors (23)

•Near Miss (28)

Approach to Improving Safety
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Error Reporting

•Governmental Reporting (18)

•Institutional Reporting (63)

•Nongovernmental Reporting (8)

•Patient Disclosure (36)

•Patient Complaints (29)

•Never Events (23)

Clinical Areas

•Allied Health Services (2)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (243)

•Health Care Executives and Administrators (387)

•Non-Health Care Professionals (145)

•Patients (49)

Setting of Care

•Hospitals (315)

•Psychiatric Facilities (2)

•Residential Facilities (13)

•Ambulatory Care (38)

•Outpatient Surgery (11)

•Patient Transport (6)

1 - 20 of 445

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STUDY

Patients' identification and reporting of unsafe events at six hospitals in Japan.

Hasegawa T, Fujita S, Seto K, Kitazawa T, Matsumoto K. Jt Comm J Qual Patient Saf. 2011;37:502-508.

STUDY

Needlestick injuries among surgeons in training.

Makary MA, Al-Attar A, Holzmueller CG, et al. N Engl J Med. 2007;356:2693-2699.

STUDY

Can we rely on patients' reports of adverse events?

Zhu J, Stuver SO, Epstein AM, Schneider EC, Weissman JS, Weingart SN. Med Care. 2011;49:948-955.

BOOK/REPORT

Inspiring Ideas and Celebrating Successes: A Guidebook to Leading Patient Safety Practices in Ontario Hospitals.

OHA Patient Safety Support Service. Toronto, Ontario, Canada: Ontario Hospital Association; 2006.

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.

STUDY

Voluntary electronic reporting of laboratory errors: an analysis of 37,532 laboratory event reports from 30 health care organizations.

Snydman LK, Harubin B, Kumar S, Chen J, Lopez RE, Salem DN. Am J Med Qual. 2012;27:147-153.

STUDY

Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST).

Heddle NM, Fung M, Hervig T, et al; BEST Collaborative. Transfusion. 2012;52:1687-1695.

STUDY

Methodological variability in detecting prescribing errors and consequences for the evaluation of interventions.

Franklin BD, Birch S, Savage I, et al. Pharmacoepidemiol Drug Saf. 2009;18:992-999.

STUDY

Automated identification of extreme-risk events in clinical incident reports.

Ong MS, Magrabi F, Coiera E. J Am Med Inform Assoc. 2012;19:e110-e118.

STUDY

Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols.

Rampersaud YR, Moro ER, Neary MA, et al. Spine. 2006;31:1503-1510.

REVIEW

Systematic review of medication safety assessment methods.

Meyer-Massetti C, Cheng CM, Schwappach DL, et al. Am J Health Syst Pharm. 2011;68:227-240.

BOOK/REPORT

Patient Safety in Canada: An Update.

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

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.

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.

STUDY

Nurses' responses to medication errors: suggestions for the development of organizational strategies to improve reporting.

Covell CL, Ritchie JA. J Nurs Care Qual. 2009;24:287-297.

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.

STUDY

Developing an adverse event reporting system using administrative data.

Bahl V, Thompson MA, Commisky EL, Anderson S, Campbell DA Jr. J Patient Saf. 2008;4:31-37.

STUDY

Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors.

Panesar SS, Carson-Stevens A, Salvilla SA, Patel B, Mirza SB, Mann B. Drug Healthc Patient Saf. 2013;5:57-65.

STUDY

Identification of adverse events at an orthopedics department in Sweden.

Unbeck M, Muren O, Lillkrona U. Acta Orthop. 2008;79:396-403.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2013.

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