AHRQ Patient Safety Network

The Collection > Error Analysis

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Safety Target

•Device-related Complications (20)

•Diagnostic Errors (67)

•Identification Errors (15)

•Discontinuities, Gaps, and Hand-Off Problems (54)

•Fatigue and Sleep Deprivation (9)

•Medication Safety (188)

•Medical Complications (37)

•Nonsurgical Procedural Complications (14)

•Surgical Complications (106)

•Transfusion Complications (4)

•Psychological and Social Complications (18)

Origin/Sponsor

•Africa (1)

•Asia (15)

•Australia and New Zealand (24)

•Central and South America (3)

•Europe (119)

•North America (403)

Resource Types

•Book/Report (16)

•Journal Article (519)

•Legislation/Regulation (2)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (21)

•Press Release/Announcement (2)

•Special or Theme Issue (6)

•Tools/Toolkit (4)

•Web Resource (3)

Error Types

•Epidemiology of Errors and Adverse Events (362)

•Active Errors (83)

•Latent Errors (42)

•Near Miss (19)

Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (30)

•Failure Mode Effects Analysis (17)

•Morbidity and Mortality Conferences (9)

•Narrative/Storytelling (5)

Clinical Areas

•Allied Health Services (3)

•Medicine (447)

•Nursing (59)

•Pharmacy (63)

Target Audience

•Health Care Providers (383)

•Health Care Executives and Administrators (450)

•Non-Health Care Professionals (132)

•Patients (13)

Setting of Care

•Hospitals (363)

•Psychiatric Facilities (4)

•Residential Facilities (11)

•Ambulatory Care (57)

•Outpatient Surgery (6)

•Patient Transport (5)

1 - 20 of 575

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STUDY

Surgical skill is predicted by the ability to detect errors.

Bann S, Khan M, Datta V, Darzi A. Am J Surg. 2005;189:412-415.

STUDY

Risk factors in patient safety: minimally invasive surgery versus conventional surgery.

Rodrigues SP, Wever AM, Dankelman J, Jansen FW. Surg Endosc. 2012;26:350-356.

COMMENTARY

The lost sponge: patient safety in the operating room.

Grant-Orser A, Davies P, Singh SS. CMAJ. 2012;184:1275-1278.

STUDY

Safe surgery: how accurate are we at predicting intra-operative blood loss?

Solon JG, Egan C, McNamara DA. J Eval Clin Pract. 2013;19:100-105.

MULTI-USE WEBSITE

Scottish Audit of Surgical Mortality.

Royal College of Physicians and Surgeons of Glasgow, 232-242 St Vincent Street, Glasgow, UK G2 5RJ.

STUDY

Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.

Hu YY, Arriaga AF, Roth EM, et al. Ann Surg. 2012;256:203-210.

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

Surgeon age and operative mortality in the United States.

Waljee JF, Greenfield LJ, Dimick JB, Birkmeyer JD. Ann Surg. 2006;244:353-362.

STUDY

Failures in communication and information transfer across the surgical care pathway: interview study.

Nagpal K, Arora S, Vats A, et al. BMJ Qual Saf. 2012;21:843-849.

SPECIAL OR THEME ISSUE

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

Amer Surg. 2006;72:985-1149

REVIEW

Fatal errors in nitrous oxide delivery.

Herff H, Paal P, von Goedecke A, Lindner KH, Keller C, Wenzel V. Anaesthesia. 2007;62:1202-1206.

STUDY

The American College of Surgeons' closed claims study: new insights for improving care.

Griffen FD, Stephens LS, Alexander JB, et al. J Am Coll Surg. 2007;204:561-569.

STUDY

Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program.

Kiran RP, Ahmed Ali U, Coffey JC, Vogel JD, Pokala N, Fazio VW. Ann Surg. 2012;256:469-475.

STUDY

Retained surgical items: a problem yet to be solved.

Stawicki SP, Moffatt-Bruce SD, Ahmed HM, et al. J Am Coll Surg. 2013;216:15-22.

STUDY

The role of surgeon error in withdrawal of postoperative life support.

Schwarze ML, Redmann AJ, Brasel KJ, Alexander GC. Ann Surg. 2012;256:10-15.

STUDY

Drug-induced hypoglycaemia--new insight into an old problem.

Ching CK, Lai CK, Poon WT, et al. Hong Kong Med J. 2006;12:334-338.

STUDY

Factors that influence the expected length of operation: results of a prospective study.

Gillespie BM, Chaboyer W, Fairweather N. BMJ Qual Saf. 2012;21:3-12.

REVIEW

Preventable errors in the operating room: retained foreign bodies after surgery--part I.

Gibbs VC, Coakley FD, Reines HD. Curr Probl Surg. 2007;44:281-337.

STUDY

Classification of adverse events occurring in a surgical intensive care unit.

Frankel H, Sperry J, Kaplan L, Foley A, Rabinovici R. Am J Surg. 2007;194:328-332.

COMMENTARY

A theory-based instrument to evaluate team communication in the operating room: balancing measurement authenticity and reliability.

Lingard L, Regehr G, Espin S, Whyte S. Qual Saf Health Care. 2006;15:422-426.

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