AHRQ Patient Safety Network

The Collection > Error Analysis

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Safety Target

•Device-related Complications (28)

•Diagnostic Errors (95)

•Identification Errors (22)

•Discontinuities, Gaps, and Hand-Off Problems (83)

•Fatigue and Sleep Deprivation (12)

•Medication Safety (251)

•Medical Complications (61)

•Nonsurgical Procedural Complications (19)

•Surgical Complications (87)

•Transfusion Complications (5)

•Psychological and Social Complications (34)

Origin/Sponsor

•Africa (1)

•Asia (13)

•Australia and New Zealand (28)

•Central and South America (1)

Resource Types

•Journal Article (694)

•Legislation/Regulation (5)

•Meeting/Conference (2)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (58)

•Press Release/Announcement (4)

•Special or Theme Issue (10)

•Tools/Toolkit (10)

•Web Resource (13)

Error Types

•Epidemiology of Errors and Adverse Events (314)

•Active Errors (141)

•Latent Errors (97)

•Near Miss (25)

Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (117)

•Failure Mode Effects Analysis (37)

•Morbidity and Mortality Conferences (18)

•Narrative/Storytelling (31)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (567)

•Health Care Executives and Administrators (677)

•Non-Health Care Professionals (282)

•Patients (55)

Setting of Care

•Hospitals (481)

•Psychiatric Facilities (3)

•Residential Facilities (14)

•Ambulatory Care (76)

•Outpatient Surgery (8)

•Patient Transport (10)

1 - 20 of 867

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NEWSPAPER/MAGAZINE ARTICLE

Survive your doctor.

Holt TE. Men's Health. November 3, 2006.

STUDY

Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers.

Kachalia A, Gandhi TK, Puopolo AL, et al. Ann Emerg Med. Ann Emerg Med. 2007;49:196-205.

BOOK/REPORT

Organisational Failure: An Exploratory Study in the Steel Industry and Medical Domain.

van Vuuren W. [dissertation]. Eindhoven, The Netherlands: Eindhoven University of Technology; 1998.

NEWSPAPER/MAGAZINE ARTICLE

Health literacy—a quality and patient safety imperative.

Foubister V. Quality Matters. November/December 2006.

NEWSPAPER/MAGAZINE ARTICLE

Maternity ward at Highland under fire from patients.

Vesely R. Inside Bay Area. December 28, 2006.

COMMENTARY

Delay in Initiating Antibiotics Leads to Fatal Error.

Bellini LM. AHRQ WebM&M [serial online]. February 2004.

STUDY

Measuring faculty reflection on adverse patient events: development and initial validation of a case-based learning system.

Wittich CM, Lopez-Jimenez F, Decker LK, et al. J Gen Intern Med. 2011;26:293-298.

STUDY

The nature and causes of unintended events reported at ten emergency departments.

Smits M, Groenewegen PP, Timmermans DRM, van der Wal G, Wagner C. BMC Emerg Med. 2009;9:16.

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.

NEWSPAPER/MAGAZINE ARTICLE

Debriefing for patient safety.

Turner SH, Kurtz WD. Patient Saf Qual Healthc. November/December 2008:5:42-44,46.

COMMENTARY

Do Not Disturb!

Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.

STUDY

The host hospital 24-hour underreferral rate: an automated measure of call-center safety.

Hirsh DA, Simon HK, Massey R, Thornton L, Simon JE. Pediatrics. 2007;119:1139-1144.

MULTI-USE WEBSITE

Joint Commission International Center for Patient Safety.

The Joint Commission, Joint Commission Resources.

NEWSPAPER/MAGAZINE ARTICLE

Q: What scares doctors? A: Being the patient.

Gibbs N, Bower A. Time Magazine. May 1, 2006.

AUDIOVISUAL

Health agency: drug errors still common.

Knox R. "All Things Considered." National Public Radio. July 20, 2006.

STUDY

Interruptions in a level one trauma center: a case study.

Brixey JJ, Tang Z, Robinson DJ, et al. Int J Med Inform. 2008;77:235-241.

BOOK/REPORT

HealthGrades Quality Study: Third Annual Patient Safety in American Hospitals Study.

Golden, CO: Health Grades, Inc.; April 2006.

SPECIAL OR THEME ISSUE

Improving Health Care Quality.

Wisc Med J. 2006:105;1-86.

COMMENTARY

Safety strategies in an academic radiation oncology department and recommendations for action.

Terezakis SA, Pronovost P, Harris K, Deweese T, Ford E. Jt Comm J Qual Patient Saf. 2011;37:291-299.

BOOK/REPORT

Safety First: a report for patients, clinicians and healthcare managers.

Carruthers I, Phillip P. London, UK: National Patient Safety Agency; 2006.

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