AHRQ Patient Safety Network

The Collection > Error Analysis

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Safety Target

•Device-related Complications (22)

•Diagnostic Errors (68)

•Identification Errors (12)

•Discontinuities, Gaps, and Hand-Off Problems (52)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (169)

•Medical Complications (43)

•Nonsurgical Procedural Complications (14)

•Surgical Complications (58)

•Transfusion Complications (4)

•Psychological and Social Complications (24)

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•Asia (7)

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•Journal Article (469)

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•Special or Theme Issue (8)

•Tools/Toolkit (6)

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•Epidemiology of Errors and Adverse Events (229)

•Active Errors (71)

•Latent Errors (42)

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Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (15)

•Failure Mode Effects Analysis (8)

•Morbidity and Mortality Conferences (6)

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Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (353)

•Health Care Executives and Administrators (449)

•Non-Health Care Professionals (168)

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Setting of Care

•Hospitals (326)

•Psychiatric Facilities (2)

•Residential Facilities (11)

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1 - 20 of 570

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COMMENTARY

Putting power into patient safety: interventions.

Astion M. Laboratory Errors & Patient Safety. May-June 2005;1:5-8.

STUDY

Surgical specimen identification errors: a new measure of quality in surgical care.

Makary MA, Epstein J, Pronovost PJ, Millman EA, Hartmann EC, Freischlag JA. Surgery. 2007;141:450-455.

STUDY

Quality improvement to decrease specimen mislabeling in transfusion medicine.

Quillen K, Murphy K. Arch Pathol Lab Med. 2006;130:1196-1198.

STUDY

Medical errors arising from outsourcing laboratory and radiology services.

Chasin BS, Elliott SP, Klotz SA. Am J Med. 2007;120:819.e9-11.

COMMENTARY classic

Five years after 'To Err is Human': what have we learned?

Leape LL, Berwick DM. JAMA. 2005;293:2384-2390.

SPECIAL OR THEME ISSUE

Patient Safety and the Invitational Conference on Contemporary Surgical Quality, Safety and Transparency.

Amer Surg. 2006;72:985-1149

STUDY

Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions.

Valenstein PN, Raab SS, Walsh MK. Arch Pathol Lab Med. 2006;130:1106-1113.

ORGANIZATIONAL POLICY/GUIDELINES

Recommendations for quality assurance and improvement in surgical and autopsy pathology.

Association of Directors of Anatomic and Surgical Pathology. Hum Pathol. 2006;37:985-988.

STUDY

Cause and effect analysis of closed claims in obstetrics and gynecology.

White AA, Pichert JW, Bledsoe SH, Irwin C, Entman SS. Obstet Gynecol. 2005;105:1031-1038.

STUDY

Increasing patient safety and efficiency in transfusion therapy using formal process definitions.

Henneman EA, Avrunin GS, Clarke LA, et al. Transfus Med Rev. 2007;21:49-57.

STUDY

Correlation of workload with disagreement and amendment rates in surgical pathology and nongynecologic cytology.

Renshaw AA, Gould EW. Am J Clin Pathol. 2006;125:820-822.

STUDY

Effectiveness of a community collaborative for eliminating the use of high-risk abbreviations written by physicians.

Leonhardt KK, Botticelli J. J Patient Saf. 2006;2:147-153.

STUDY

The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer.

Raab SS, Meier FA, Zarbo RJ, et al. J Clin Oncol. 2006;24:2808-2814.

STUDY

CT for suspected appendicitis in children: an analysis of diagnostic errors.

Taylor GA, Callahan MJ, Rodriguez D, Smink DS. Pediatr Radiol. 2006;36:331-337.

STUDY

The frequency of missed test results and associated treatment delays in a highly computerized health system.

Wahls TL, Cram PM. BMC Fam Pract. 2007;8:32.

MEASUREMENT TOOL/INDICATOR

The Physician Practice Patient Safety Assessment.

Medical Group Management Association Center for Research, Health Research and Educational Trust, Institute for Safe Medication Practices. 2005.

STUDY

Finding blunders in thyroid testing: experience in newborns.

Zilka LJ, Lott JA, Baker LC, Linard SM. J Clin Lab Anal. 2008;22:254-256.

STUDY

The safety of hospital stroke care.

Holloway RG, Tuttle D, Baird T, Skelton WK. Neurology. 2007;68:550-555.

STUDY

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

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

STUDY

The impact of abbreviations on patient safety.

Brunetti L, Santell JP, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:576-583.

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