AHRQ Patient Safety Network

The Collection > Institutional Reporting

PATIENT SAFETY PRIMERS
Voluntary Patient Safety Event Reporting (Incident Reporting)

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Safety Target

•Device-related Complications (3)

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•Identification Errors (3)

•Discontinuities, Gaps, and Hand-Off Problems (6)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (43)

•Medical Complications (11)

•Nonsurgical Procedural Complications (3)

•Surgical Complications (4)

•Transfusion Complications (1)

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•Journal Article (99)

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•Special or Theme Issue (1)

•Tools/Toolkit (1)

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•Epidemiology of Errors and Adverse Events (46)

•Active Errors (15)

•Latent Errors (7)

•Near Miss (8)

Approach to Improving Safety
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Institutional Reporting

Clinical Areas

•Allied Health Services (1)

•Medicine (78)

•Nursing (14)

•Pharmacy (11)

Target Audience

•Health Care Providers (70)

•Health Care Executives and Administrators (109)

•Non-Health Care Professionals (43)

•Patients (6)

Setting of Care

•Hospitals (95)

•Psychiatric Facilities (2)

•Residential Facilities (3)

•Ambulatory Care (6)

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•Patient Transport (2)

1 - 20 of 121

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STUDY

A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths.

de Feijter JM, de Grave WS, Muijtjens AM, Scherpbier AJ, Koopmans RP. PLoS One. 2012;7:e31125.

STUDY

'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured.

Classen DC, Resar R, Griffin F, et al. Health Aff (Millwood). 2011;30:581-589.

NEWSPAPER/MAGAZINE ARTICLE

Tapping front-line knowledge: identifying problems as they occur helps enhance patient safety.

Luther K, Resar RK. Healthc Exec. Jan/Feb 2013;28:84-87.

NEWSPAPER/MAGAZINE ARTICLE

Washington Hospital Center safety program seeks to catch 'near-misses.'

Sun LH. Washington Post. August 2, 2011.

STUDY

Patient safety reporting systems: sustained quality improvement using a multidisciplinary team and "Good Catch" awards.

Herzer KR, Mirrer M, Xie Y, et al. Jt Comm J Qual Patient Saf. 2012;38:339-347.

STUDY

How event reporting by US hospitals has changed from 2005 to 2009.

Farley DO, Haviland A, Haas A, Pham C, Munier WB, Battles JB. BMJ Qual Saf. 2012;21:70-77.

STUDY

Reported medication errors after introducing an electronic medication management system.

Redley B, Botti M. J Clin Nurs. 2013;22:579-589.

STUDY

A novel approach to increase residents' involvement in reporting adverse events.

Scott DR, Weimer M, English C, et al. Acad Med. 2011;86:742-746.

BOOK/REPORT

Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems.

Glenview, IL: National Association of Healthcare Quality; October 2012.

STUDY

Description and evaluation of adaptations to the Global Trigger Tool to enhance value to adverse event reduction efforts.

Kennerly DA, Saldaña M, Kudyakov R, da Graca B, Nicewander D, Compton J. J Patient Saf. 2013 Jan 30; [Epub ahead of print].

NEWSPAPER/MAGAZINE ARTICLE

No bad apples.

Thrall TH. Hosp Health Netw. December 2008.

STUDY

Patient safety event reporting in critical care: a study of three intensive care units.

Harris CB, Krauss MJ, Coopersmith CM, et al. Crit Care Med. 2007;35:1068-1076.

NEWSPAPER/MAGAZINE ARTICLE

U.S. to delete data on life-threatening mistakes from website.

Babcock CR. Bloomberg News. May 1, 2013.

NEWSPAPER/MAGAZINE ARTICLE

Fear of punitive response to hospital errors lingers.

O'Reilly KB. American Medical News. February 20, 2012.

BOOK/REPORT classic

Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 2012. Report No. OEI-06-09-00091.

COMMENTARY

Using incident reporting to improve patient safety: a conceptual model.

Pronovost PJ, Holzmueller CG, Young J, et al. J Patient Saf. 2007;3:27-33.

SPECIAL OR THEME ISSUE

Hospital Transparency in Reporting Medical Errors.

Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 23, 2010.

STUDY

Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant.

Levtzion-Korach O, Frankel A, Alcalai H, et al. Jt Comm J Qual Patient Saf. 2010;36:402-410.

BOOK/REPORT

Standing Up for Doctors, Speaking Out for Patients. Final Report.

London, UK: Health Policy & Economic Research Unit, British Medical Association Scotland; May 2010.

STUDY

From the school of nursing quality and safety officer: nursing students' use of safety reporting tools and their perception of safety issues in clinical settings.

Cooper E. J Prof Nurs. 2013;29:109-116.

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