AHRQ Patient Safety Network

The Collection > Error Analysis

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Safety Target

•Device-related Complications (27)

•Diagnostic Errors (94)

•Identification Errors (16)

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

•Fatigue and Sleep Deprivation (10)

•Medication Safety (225)

•Medical Complications (46)

•Nonsurgical Procedural Complications (18)

•Surgical Complications (84)

•Transfusion Complications (5)

•Psychological and Social Complications (26)

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•Asia (12)

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•Central and South America (2)

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•Journal Article (625)

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•Meeting/Conference (2)

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•Newspaper/Magazine Article (46)

•Press Release/Announcement (3)

•Special or Theme Issue (8)

•Tools/Toolkit (7)

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Error Types

•Epidemiology of Errors and Adverse Events (290)

•Active Errors (110)

•Latent Errors (57)

•Near Miss (17)

Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (54)

•Failure Mode Effects Analysis (27)

•Morbidity and Mortality Conferences (13)

•Narrative/Storytelling (11)

Clinical Areas

•Allied Health Services (1)

Target Audience

•Health Care Providers (464)

•Health Care Executives and Administrators (583)

•Non-Health Care Professionals (212)

•Patients (29)

Setting of Care

•Hospitals (407)

•Psychiatric Facilities (2)

•Residential Facilities (12)

•Ambulatory Care (66)

•Outpatient Surgery (3)

•Patient Transport (3)

1 - 20 of 732

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STUDY

Outside case review of surgical pathology for referred patients: the impact on patient care.

Swapp RE, Aubry MC, Salomão DR, Cheville JC. Arch Pathol Lab Med. 2013;137:233-240.

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

Medical errors arising from outsourcing laboratory and radiology services.

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

STUDY

Quantitative assessment of workload and stressors in clinical radiation oncology.

Mazur LM, Mosaly PR, Jackson M, et al. Int J Radiat Oncol Biol Phys. 2012;83:e571-e576.

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.

REVIEW

Measuring errors in surgical pathology in real-life practice: defining what does and does not matter.

Renshaw AA, Gould EW. Am J Clin Path. 2007;127:144-152.

REVIEW

Singh H, Graber ML, Kissam SM, et al. BMJ Qual Saf. 2012;21:160-170.

STUDY

Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular examinations for orthopedic trauma patients.

Tan EW, Ting BL, Jia XF, Skolasky RL, McFarland EG. Am J Med Qual. 2013;28:60-68.

STUDY

Identifying diagnostic errors in primary care using an electronic screening algorithm.

Singh H, Thomas EJ, Khan MM, Petersen LA. Arch Intern Med. 2007;167:302-308.

STUDY

Uncharted territory: measuring costs of diagnostic errors outside the medical record.

Schwartz A, Weiner SJ, Weaver F, et al. BMJ Qual Saf. 2012;21:918-924.

COMMENTARY

Database construction for improving patient safety by examining pathology errors.

Grzybicki DM, Turcsanyi B, Becich MJ, Gupta D, Gilbertson JR, Raab SS. Am J Clin Pathol. 2005;124:500-509.

NEWSPAPER/MAGAZINE ARTICLE

Are you a great diagnostician?

Yasgur BS. Medscape Business of Medicine. March 27, 2013.

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 "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.

SPECIAL OR THEME ISSUE

Special Section—Association of Directors of Anatomic and Surgical Pathology Symposium.

Arch Pathol Lab Med. 2006;130:602-649.

REVIEW

The medicolegal aspect of error in pathology: a search of jury verdicts and settlements.

Kornstein MJ, Byrne SP. Arch Pathol Lab Med. 2007;131:615-618.

STUDY

Accuracies of diagnostic methods for acute appendicitis.

Park JS, Jeong JH, Lee JI, Lee JH, Park JK, Moon HJ. Am Surg. 2013;79:101-106.

STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

STUDY

Colonoscopic withdrawal times and adenoma detection during screening colonoscopy.

Barclay RL, Vicari JJ, Doughty AS, Johanson JF, Greenlaw RL. N Engl J Med. 2006;355:2533-2541.

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