AHRQ Patient Safety Network

The Collection > Error Analysis

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Safety Target

•Device-related Complications (15)

•Diagnostic Errors (47)

•Identification Errors (7)

•Discontinuities, Gaps, and Hand-Off Problems (47)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (181)

•Medical Complications (59)

•Nonsurgical Procedural Complications (15)

•Surgical Complications (48)

•Transfusion Complications (3)

•Psychological and Social Complications (24)

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•Asia (15)

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•Central and South America (1)

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•Journal Article (474)

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•Newsletter/Journal (3)

•Newspaper/Magazine Article (42)

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•Special or Theme Issue (9)

•Tools/Toolkit (9)

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Error Types

•Epidemiology of Errors and Adverse Events (223)

•Active Errors (82)

•Latent Errors (63)

•Near Miss (19)

Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (59)

•Failure Mode Effects Analysis (21)

•Morbidity and Mortality Conferences (11)

•Narrative/Storytelling (11)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (419)

•Health Care Executives and Administrators (493)

•Non-Health Care Professionals (208)

•Patients (37)

Setting of Care

•Hospitals (402)

•Psychiatric Facilities (3)

•Residential Facilities (8)

•Ambulatory Care (65)

•Outpatient Surgery (4)

•Patient Transport (5)

1 - 20 of 602

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BOOK/REPORT classic

Making Health Care Safer: A Critical Analysis of Patient Safety Practices.

Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2001. AHRQ Publication No. 01-E058.

MULTI-USE WEBSITE

Indiana Medical Error Reporting System.

Indiana State Department of Health.

BOOK/REPORT

2006 National Healthcare Quality Report.

Rockville, MD: Agency for Healthcare Research and Quality; 2006. AHRQ Publication No. 07-0013.

STUDY

Measuring hospital-wide activity volume for patient safety and infection control: a multi-centre study in Japan.

Hayashida K, Imanaka Y, Fukuda H. BMC Health Serv Res. 2007;7:140.

NEWSPAPER/MAGAZINE ARTICLE

Survive your doctor.

Holt TE. Men's Health. November 3, 2006.

COMMENTARY

Understanding medication safety in healthcare settings: a critical review of conceptual models.

Liu W, Manias E, Gerdtz M. Nurs Inq. 2011;18:290-302.

NEWSPAPER/MAGAZINE ARTICLE

Studies on medical errors warrant a second opinion.

Bialik C. The Wall Street Journal Online. June 29, 2006.

COMMENTARY

Is the measurement mandate diverting the patient safety revolution?

Wachter RM. National Quality Measures Clearinghouse (NQMC). March 3, 2008.

STUDY

Measuring safety culture in the ambulatory setting: The Safety Attitudes Questionnaire—Ambulatory Version.

Modak I, Sexton JB, Lux TR, Helmreich RL, Thomas EJ. J Gen Intern Med. 2007;22:1-5.

BOOK/REPORT

Compendium 2000-2005.

Washington, DC: National Quality Forum; 2006. ISBN: 1933875003.

BOOK/REPORT

HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada.

Ottawa, ON, Canada: Canadian Institute for Health Information; 2007. ISBN: 9781554651849.

MEASUREMENT TOOL/INDICATOR

2005 ISMP Medication Safety Self Assessment® for Antithrombotic Therapy in Hospitals.

Huntingdon Valley, PA: Institute for Safe Medication Practices; 2005.

COMMENTARY classic

Safe but sound: patient safety meets evidence-based medicine.

Shojania KG, Duncan BW, McDonald KM, Wachter RM. JAMA. 2002;288:508-513.

STUDY

Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians.

Davidenko JM, Snyder LS. J Electrocardiol. 2007;40:450-457.

COMMENTARY

A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary.

Walshe K, Offen N. Qual Health Care. 2001;10:250-256.

STUDY

Contemporary evidence about hospital strategies for reducing 30-day readmissions: a national study.

Bradley EH, Curry L, Horwitz LI, et al. J Am Coll Cardiol. 2012;60:607-614.

STUDY

Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study.

Sinopoli DJ, Needham DM, Thompson DA, et al. J Crit Care. 2007;22:177-183.

STUDY

Chemotherapeutic errors in hospitalised cancer patients: attributable damage and extra costs.

Ranchon F, Salles G, Späth HM, et al. BMC Cancer. 2011;11:478.

STUDY

French national survey of inpatient adverse events prospectively assessed with ward staff.

Michel P, Quenon JL, Djihoud A, Tricaud-Vialle S, de Sarasqueta AM. Qual Saf Health Care. 2007;16:369-377.

NEWSPAPER/MAGAZINE ARTICLE

Practitioners agree on medication reconciliation value, but frustration and difficulties abound.

ISMP Medication Safety Alert! Acute Care Edition. July 13, 2006;11:1-2.

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