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 (2)

•Diagnostic Errors (3)

•Discontinuities, Gaps, and Hand-Off Problems (3)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (25)

•Medical Complications (4)

•Nonsurgical Procedural Complications (1)

•Transfusion Complications (1)

•Psychological and Social Complications (5)

Origin/Sponsor

•Asia (5)

•Australia and New Zealand (5)

•Europe (13)

•North America (51)

Resource Types

•Book/Report (3)

•Journal Article (63)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (10)

•Special or Theme Issue (1)

•Tools/Toolkit (1)

Error Types

•Epidemiology of Errors and Adverse Events (29)

•Active Errors (8)

•Latent Errors (5)

•Near Miss (6)

Approach to Improving Safety
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Institutional Reporting

Clinical Areas

•Allied Health Services (1)

•Medicine (50)

•Nursing (10)

•Pharmacy (8)

Target Audience

•Health Care Providers (43)

•Health Care Executives and Administrators (70)

•Non-Health Care Professionals (31)

•Patients (3)

Setting of Care

•Hospitals (70)

•Ambulatory Care (1)

•Outpatient Surgery (1)

1 - 20 of 79

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STUDY

Results of a survey on medical error reporting systems in Korean hospitals.

Kim J, Bates DW. Int J Med Inform. 2006;75:148-155.

STUDY

Can incident reporting improve safety? Healthcare practitioners' views of the effectiveness of incident reporting.

Anderson JE, Kodate N, Walters R, Dodds A. Int J Qual Health Care. 2013;25:141-150.

STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

STUDY

Barriers to nurses' reporting of medication administration errors in Taiwan.

Chiang HY, Pepper GA. J Nurs Scholarsh. 2006;38:392-399.

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

Anatomic pathology databases and patient safety.

Raab SS, Grzybicki DM, Zarbo RJ, Meier FA, Geyer SJ, Jensen C. Arch Pathol Lab Med. 2005;129:1246-1251.

NEWSPAPER/MAGAZINE ARTICLE

Fixing America's hospitals.

Newsweek. October 16, 2006:44-68, 72.

COMMENTARY

In Conversation with…Jennifer Daley, MD

AHRQ WebM&M [serial online]. January 2008

STUDY

Implementation of a patient safety incident management system as viewed by doctors, nurses and allied health professionals.

Travaglia JF, Westbrook MT, Braithwaite J. Health (London). 2009;13:277-296.

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.

REVIEW

Can technology improve intershift report? What the research reveals.

Strople B, Ottani P. J Prof Nurs. 2006;22:197-204.

STUDY

Getting doctors to report medical errors: project DISCLOSE.

King ES, Moyer DV, Couturie MJ, Gaughan JP, Shulkin DJ. Jt Comm J Qual Patient Saf. 2006;32:382-392.

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.

COMMENTARY

Shake Well.

Flynn EA. AHRQ WebM&M [serial online]. September 2003.

STUDY

Reported medication errors after introducing an electronic medication management system.

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

STUDY

Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review.

Sari AB, Sheldon TA, Cracknell A, Turnbull A. BMJ. 2007;334;79.

COMMENTARY

Between a rock and a hard place: disclosing medical errors.

Crone KG, Muraski MB, Skeel JD, Love-Gregory L, Ladenson JH, Gronowski AM. Clin Chem. 2006;52:1809-1814.

NEWSPAPER/MAGAZINE ARTICLE

Fear of punitive response to hospital errors lingers.

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

NEWSPAPER/MAGAZINE ARTICLE

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

Babcock CR. Bloomberg News. May 1, 2013.

STUDY

Identifying, understanding and overcoming barriers to medication error reporting in hospitals: a focus group study.

Hartnell N, MacKinnon N, Sketris I, Fleming M. BMJ Qual Saf. 2012;21:361-368.

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