AHRQ Patient Safety Network

The Collection > Error Analysis

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Safety Target

•Device-related Complications (27)

•Diagnostic Errors (87)

•Identification Errors (20)

•Discontinuities, Gaps, and Hand-Off Problems (60)

•Fatigue and Sleep Deprivation (9)

•Medication Safety (273)

•Medical Complications (56)

•Nonsurgical Procedural Complications (17)

•Surgical Complications (100)

•Transfusion Complications (5)

•Psychological and Social Complications (25)

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•Asia (18)

•Australia and New Zealand (35)

•Central and South America (3)

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•Journal Article (719)

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•Meeting/Conference (1)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (48)

•Press Release/Announcement (5)

•Special or Theme Issue (9)

•Tools/Toolkit (7)

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Error Types

•Epidemiology of Errors and Adverse Events (382)

•Active Errors (109)

•Latent Errors (62)

•Near Miss (21)

Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (81)

•Failure Mode Effects Analysis (38)

•Morbidity and Mortality Conferences (18)

•Narrative/Storytelling (9)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (511)

•Health Care Executives and Administrators (679)

•Non-Health Care Professionals (243)

•Patients (36)

Setting of Care

•Hospitals (466)

•Psychiatric Facilities (4)

•Residential Facilities (14)

•Ambulatory Care (80)

•Outpatient Surgery (6)

•Patient Transport (8)

1 - 20 of 843

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STUDY

Decreasing errors in pediatric continuous intravenous infusions.

Lehmann CU, Kim GR, Gujral R, Veltri MA, Clark JS, Miller MR. Pediatr Crit Care Med. 2006;7:225-230.

STUDY

Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium.

Cravero JP, Blike GT, Beach M, et al. Pediatrics. 2006;118:1087-1096.

STUDY

Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.

Han YY, Carcillo JA, Venkataraman ST, et al. Pediatrics. 2005;116:1506-1512.

STUDY

Antiretroviral medication errors among hospitalized patients with HIV infection.

Rastegar DA, Knight AM, Monolakis JS. Clin Infect Dis. 2006;43:933-38.

STUDY

Anatomy of a patient safety event: a pediatric patient safety taxonomy.

Woods DM, Johnson J, Holl JL, et al. Qual Saf Health Care. 2005;14:422-427.

STUDY

Adverse drug events caused by serious medication administration errors.

Kale A, Keohane CA, Maviglia S, Gandhi TK, Poon EG. BMJ Qual Saf. 2012;21:933-938.

STUDY

Adverse drug event reporting in intensive care units: a survey of current practices.

Kane-Gill SL, Devlin JW. Ann Pharmacother. 2006;40:1267-73.

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.

COMMENTARY

Lessons from "unexpected increased mortality after implementation of a commercially sold computerized physician order entry system."

Sittig DF, Ash JS, Zhang J, Osheroff JA, Shabot MM. Pediatrics. 2006;118:797-801.

STUDY

Preventable harm occurring to critically ill children.

Larsen GY, Donaldson AE, Parker HB, Grant MJ. Pediatr Crit Care Med. 2007;8:331-336.

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

Review of the Australian Incident Monitoring System.

Spigelman AD, Swan J. ANZ J Surg. 2005;75:657-661.

STUDY

Intralipid medication errors in the neonatal intensive care unit.

Chuo J, Lambert G, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:104-111.

STUDY

Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children with cancer.

Robinson DL, Heigham M, Clark J. Jt Comm J Qual Patient Saf. 2006;32:161-166.

STUDY

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.

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.

STUDY

Inadvertent misadministration of meningococcal conjugate vaccine—United States, June–August 2005.

Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2006;55:1016-1017.

STUDY

Diagnostic errors with inserted tubes, lines and catheters in children.

Fuentealba I, Taylor GA. Pediatr Radiol. 2012;42:1305-1315.

COMMENTARY

Appropriate prescribing of medications: an eight-step approach.

Pollock M, Bazaldua OV, Dobbie AE. Am Fam Physician. 2007;75:231-236, 239-240.

STUDY

Scrutinizing incident reporting in anaesthesia: why is an incident perceived as critical?

Maaloe R, la Cour M, Hansen A, et al. Acta Anaesthesiol Scand. 2006;50:1005-1013.

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