AHRQ Patient Safety Network

The Collection > Error Analysis

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Safety Target

•Device-related Complications (34)

•Diagnostic Errors (96)

•Identification Errors (23)

•Discontinuities, Gaps, and Hand-Off Problems (84)

•Fatigue and Sleep Deprivation (13)

•Medication Safety (266)

•Medical Complications (65)

•Nonsurgical Procedural Complications (17)

•Surgical Complications (98)

•Transfusion Complications (4)

•Psychological and Social Complications (32)

Origin/Sponsor

•Africa (1)

•Asia (20)

•Australia and New Zealand (33)

•Central and South America (3)

Resource Types

•Journal Article (752)

•Legislation/Regulation (3)

•Meeting/Conference (2)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (55)

•Press Release/Announcement (3)

•Special or Theme Issue (8)

•Tools/Toolkit (8)

•Web Resource (10)

Error Types

•Epidemiology of Errors and Adverse Events (336)

•Active Errors (136)

•Latent Errors (91)

•Near Miss (23)

Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (90)

•Failure Mode Effects Analysis (47)

•Morbidity and Mortality Conferences (22)

•Narrative/Storytelling (20)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (547)

•Health Care Executives and Administrators (702)

•Non-Health Care Professionals (286)

•Patients (39)

Setting of Care

•Hospitals (532)

•Psychiatric Facilities (4)

•Residential Facilities (14)

•Ambulatory Care (80)

•Outpatient Surgery (7)

•Patient Transport (7)

1 - 20 of 886

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STUDY

"Did I do as best as the system would let me?" Healthcare professional views on hospital to home care transitions.

Davis MM, Devoe M, Kansagara D, Nicolaidis C, Englander H. J Gen Intern Med. 2012;27:1649-1656.

REVIEW

Research on nursing handoffs for medical and surgical settings: an integrative review.

Staggers N, Blaz JW. J Adv Nurs. 2013;69:247-262.

STUDY

The association between frequency of self-reported medical errors and anesthesia trainee supervision: a survey of United States anesthesiology residents-in-training.

De Oliveira GS Jr, Rahmani R, Fitzgerald PC, Chang R, McCarthy RJ. Anesth Analg. 2013;116:892-897.

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

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

Cognitive errors detected in anaesthesiology: a literature review and pilot study.

Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Br J Anaesth. 2012;108:229-235.

STUDY

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.

STUDY

Supratherapeutic dosing of acetaminophen among hospitalized patients.

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

STUDY

Using the patient safety indicators to detect potential safety events among US veterans with psychotic disorders: clinical and research implications.

Smith EG, Zhao S, Rosen AK. Int J Qual Health Care. 2012;24:321-329.

STUDY

Resident uncertainty in clinical decision making and impact on patient care: a qualitative study.

Farnan JM, Johnson JK, Meltzer DO, Humphrey HJ, Arora VM. Qual Saf Health Care. 2008;17:122-126.

COMMENTARY

Critical conversations: a call for a nonprocedural "time out."

Sehgal NL, Fox M, Sharpe BA, Vidyarthi AR, Blegen M, Wachter RM. J Hosp Med. 2011;6:157-162.

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.

REVIEW

Diagnostic errors in the intensive care unit: a systematic review of autopsy studies.

Winters B, Custer J, Galvagno SM Jr, et al. BMJ Qual Saf. 2012;21:894-902.

STUDY

Junior doctors' reflections on patient safety.

Ahmed M, Arora S, Carley S, Sevdalis N, Neale G. Postgrad Med J. 2012;88:125-129.

STUDY

Resident perceptions of the impact of work hour limitations.

Lin GA, Beck DC, Stewart AL, Garbutt JM. J Gen Intern Med. 2007;22:969-975.

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.

COMMENTARY

Using the opportunity estimator tool to improve engagement in a quality and safety intervention.

Duval-Arnould J, Mathews SC, Weeks K, et al. Jt Comm J Qual Patient Saf. 2012;38:41-47.

STUDY

Organizational culture: an important context for addressing and improving hospital to community patient discharge.

Hesselink G, Vernooij-Dassen M, Pijnenborg L, et al; European HANDOVER Research Collaborative. Med Care. 2013;51:90-98.

STUDY

Identifying the latent failures underpinning medication administration errors: an exploratory study.

Lawton R, Carruthers S, Gardner P, Wright J, McEachan RR. Health Serv Res. 2012;47:1437-1459.

COMMENTARY

Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.

Acquaviva K, Haskell H, Johnson J. J Prof Nurs. 2013;29:95-101.

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