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 (4)

•Diagnostic Errors (7)

•Identification Errors (3)

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

•Fatigue and Sleep Deprivation (2)

•Medication Safety (40)

•Medical Complications (11)

•Nonsurgical Procedural Complications (3)

•Surgical Complications (5)

•Transfusion Complications (2)

•Psychological and Social Complications (8)

Origin/Sponsor

•Asia (5)

•Australia and New Zealand (4)

Resource Types

•Journal Article (94)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (13)

•Special or Theme Issue (1)

•Tools/Toolkit (1)

Error Types

•Epidemiology of Errors and Adverse Events (53)

•Active Errors (14)

•Latent Errors (7)

•Near Miss (10)

Approach to Improving Safety
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Institutional Reporting

Clinical Areas

•Medicine (76)

•Nursing (9)

•Pharmacy (11)

Target Audience

•Health Care Providers (64)

•Health Care Executives and Administrators (104)

•Non-Health Care Professionals (41)

•Patients (6)

Setting of Care

•Hospitals (96)

•Psychiatric Facilities (2)

•Residential Facilities (2)

•Ambulatory Care (6)

•Outpatient Surgery (1)

•Patient Transport (2)

1 - 20 of 115

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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.

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].

COMMENTARY

Creating an oversight infrastructure for electronic health record–related patient safety hazards.

Singh H, Classen DC, Sittig DF. J Patient Saf. 2011;7:169-174.

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.

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.

STUDY

Patient expectations of fair complaint handling in hospitals: empirical data.

Friele RD, Sluijs EM. BMC Health Serv Res. 2006;6:106.

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.

STUDY

Factors influencing perioperative nurses' error reporting preferences.

Espin S, Regehr G, Levinson W, Baker GR, Biancucci C, Lingard L. AORN J. 2007;85:527-528, 530-532, 534-536, 539-543.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

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

Babcock CR. Bloomberg News. May 1, 2013.

STUDY

Retrospective analysis of medication incidents reported using an on-line reporting system.

Ashcroft DM, Cooke J. Pharm World Sci. 2006;28:359-65.

NEWSPAPER/MAGAZINE ARTICLE

No bad apples.

Thrall TH. Hosp Health Netw. December 2008.

BOOK/REPORT

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

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

SPECIAL OR THEME ISSUE

Hospital Transparency in Reporting Medical Errors.

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

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.

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

To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports?

Christiaans-Dingelhoff I, Smits M, Zwaan L, Lubberding S, van der Wal G, Wagner C. BMC Health Serv Res. 2011;11:49.

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