AHRQ Patient Safety Network

The Collection > Error Analysis

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Safety Target

•Device-related Complications (27)

•Diagnostic Errors (89)

•Identification Errors (23)

•Discontinuities, Gaps, and Hand-Off Problems (69)

•Fatigue and Sleep Deprivation (11)

•Medication Safety (275)

•Medical Complications (63)

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•Journal Article (726)

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Error Types

•Epidemiology of Errors and Adverse Events (388)

•Active Errors (118)

•Latent Errors (70)

•Near Miss (26)

Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (98)

•Failure Mode Effects Analysis (38)

•Morbidity and Mortality Conferences (22)

•Narrative/Storytelling (24)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (578)

•Health Care Executives and Administrators (690)

•Non-Health Care Professionals (263)

•Patients (50)

Setting of Care

•Hospitals (498)

•Psychiatric Facilities (5)

•Residential Facilities (15)

•Ambulatory Care (89)

•Outpatient Surgery (8)

•Patient Transport (8)

1 - 20 of 883

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STUDY

Venous thromboembolism after trauma: a never event?

Thorson CM, Ryan ML, Van Haren RM, et al. Crit Care Med. 2012;40:2967-2973.

STUDY

Reevaluating recovery: perceived violations and preemptive interventions on emergency psychiatry rounds.

Cohen T, Blatter B, Almeida C, Patel VL. J Am Med Inform Assoc. 2007;14:312-319.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: when pharmacy is closed.

PA-PSRS Patient Saf Advis. March 2012;9:11-17.

STUDY

Adverse drug events resulting from patient errors in older adults.

Field TS, Mazor KM, Briesacher B, Debellis KR, Gurwitz JH. J Am Geriatr Soc. 2007;55:271-276.

STUDY

Impact of attending physician workload on patient care: a survey of hospitalists.

Michtalik HJ, Yeh H, Pronovost PJ, Brotman DJ. JAMA Intern Med. 2013;173:375-377.

STUDY

Smartphone use during inpatient attending rounds: prevalence, patterns and potential for distraction.

Katz-Sidlow RJ, Ludwig A, Miller S, Sidlow R. J Hosp Med. 2012;7:595-599.

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

Anticoagulation-associated adverse drug events.

Piazza G, Nguyen TN, Cios D, et al. Am J Med. 2011;124:1136-1142.

NEWSPAPER/MAGAZINE ARTICLE

Events associated with the prescribing, dispensing, and administering of medication loading doses.

Carson SL, Gaunt MJ. PA-PSRS Patient Saf Advis. 2012;9:82-88.

STUDY

Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals.

Feigenbaum P, Neuwirth E, Trowbridge L, et al. Med Care. 2012;50:599-605.

STUDY

Safety climate and medical errors in 62 US emergency departments.

Camargo CA Jr, Tsai CL, Sullivan AF, et al. Ann Emerg Med. 2012;60:555-563.e20.

STUDY

Economic measurement of medical errors using a hospital claims database.

David G, Gunnarsson CL, Waters HC, Horblyuk R, Kaplan HS. Value Health. 2013;16:305-310.

STUDY

Medication reconciliation for reducing drug-discrepancy adverse events.

Boockvar KS, Carlson Lacorte H, Giambanco V, Fridman B, Siu A. Am J Geriatr Pharmacother. 2006;4:236-243.

STUDY

Medication errors among acutely ill and injured children treated in rural emergency departments.

Marcin JP, Dharmar M, Cho M, et al. Ann Emerg Med. 2007;50:361-367.e1-2.

COMMENTARY

Smart pumps: advanced capabilities and continuous quality improvement.

Vanderveen T. Patient Saf Quality Healthc. January/February 2007.

STUDY

Severity and probability of harm of medication errors intercepted by an emergency department pharmacist.

Patanwala AE, Hays DP, Sanders AB, Erstad BL. Int J Pharm Pract. 2011;19:358-362.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

STUDY

Supratherapeutic dosing of acetaminophen among hospitalized patients.

Zhou L, Maviglia SM, Mahoney LM, et al. Arch Intern Med. 2012;172:1721-1728.

STUDY

Impact of diagnosis-timing indicators on measures of safety, comorbidity, and case mix groupings from administrative data sources.

Naessens JM, Campbell CR, Berg B, Williams AR, Culbertson R. Med Care. 2007;45:781-788.

STUDY

The cost of serious fall-related injuries at three midwestern hospitals.

Wong CA, Recktenwald AJ, Jones ML, Waterman BM, Bollini ML, Dunagan WC. Jt Comm J Qual Patient Saf. 2011;37:81-87.

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