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 (7)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (44)

•Medical Complications (12)

•Nonsurgical Procedural Complications (3)

•Surgical Complications (6)

•Transfusion Complications (2)

•Psychological and Social Complications (7)

Origin/Sponsor

•Asia (4)

•Australia and New Zealand (4)

•Europe (23)

•North America (89)

Resource Types

•Book/Report (3)

•Journal Article (104)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (14)

•Special or Theme Issue (2)

•Tools/Toolkit (1)

Error Types

•Epidemiology of Errors and Adverse Events (49)

•Active Errors (16)

•Latent Errors (7)

•Near Miss (10)

Approach to Improving Safety
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Institutional Reporting

Clinical Areas

•Allied Health Services (1)

•Medicine (81)

•Nursing (13)

•Pharmacy (11)

Target Audience

•Health Care Providers (70)

•Health Care Executives and Administrators (114)

•Non-Health Care Professionals (45)

•Patients (5)

Setting of Care

•Hospitals (96)

•Psychiatric Facilities (2)

•Residential Facilities (3)

•Ambulatory Care (6)

•Outpatient Surgery (1)

•Patient Transport (2)

1 - 20 of 125

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NEWSPAPER/MAGAZINE ARTICLE

Fixing America's hospitals.

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

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

Evaluation of an anonymous system to report medical errors in pediatric inpatients.

Taylor JA, Brownstein D, Klein EJ, Strandjord TP. J Hosp Med. 2007;2:226-33.

STUDY

The interrelationship of isolation precautions and adverse events in an acute care facility.

Spence MR, McQuaid M. Am J Infect Control. 2011;39:154-155.

COMMENTARY

Developing a medication patient safety program — infrastructure and strategy.

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

NEWSPAPER/MAGAZINE ARTICLE

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

Sun LH. Washington Post. August 2, 2011.

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

Program encourages reporting accidents waiting to happen: the Good Catch Awards.

McCook A. Anesthesiology News. Sept 2011;37:9.

COMMENTARY

Urine a Tough Position.

Gandhi TK. AHRQ WebM&M [serial online]. October 2003.

NEWSPAPER/MAGAZINE ARTICLE

Case study: sustaining a culture of safety in the U.S. Department of Veterans Affairs Health Care System.

Chase D, McCarthy D. Quality Matters. April/May 2010.

COMMENTARY

Delay in Initiating Antibiotics Leads to Fatal Error.

Bellini LM. AHRQ WebM&M [serial online]. February 2004.

STUDY

A comprehensive obstetrics patient safety program improves safety climate and culture.

Pettker CM, Thung SF, Raab CA, et al. Am J Obstet Gynecol. 2011;204:216.e1-e6.

NEWSPAPER/MAGAZINE ARTICLE

Fear of punitive response to hospital errors lingers.

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

NEWSPAPER/MAGAZINE ARTICLE

Doctor removes ovaries from wrong patient.

Bramson K, Mooney T. Providence Journal. August 18, 2006.

COMMENTARY

In Conversation with…Jennifer Daley, MD

AHRQ WebM&M [serial online]. January 2008

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

A human factors and survey methodology-based design of a web-based adverse event reporting system for families.

Daniels JP, King AD, Cochrane DD, et al. Int J Med Inform. 2010;79:339-348.

STUDY

Lessons learned: use of event reporting by nurses to improve patient safety and quality.

Hession-Laband E, Mantell P. J Pediatr Nurs. 2011;26:149-155.

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].

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