AHRQ Patient Safety Network

The Collection > Error Analysis

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Safety Target

•Device-related Complications (28)

•Diagnostic Errors (88)

•Identification Errors (23)

•Discontinuities, Gaps, and Hand-Off Problems (64)

•Fatigue and Sleep Deprivation (10)

•Medication Safety (280)

•Medical Complications (57)

•Nonsurgical Procedural Complications (17)

•Surgical Complications (101)

•Transfusion Complications (5)

•Psychological and Social Complications (27)

Origin/Sponsor

•Asia (18)

•Australia and New Zealand (39)

•Central and South America (3)

Resource Types

•Journal Article (726)

•Legislation/Regulation (3)

•Meeting/Conference (1)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (47)

•Press Release/Announcement (4)

•Special or Theme Issue (9)

•Tools/Toolkit (10)

•Web Resource (5)

Error Types

•Epidemiology of Errors and Adverse Events (386)

•Active Errors (113)

•Latent Errors (65)

•Near Miss (21)

Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (78)

•Failure Mode Effects Analysis (41)

•Morbidity and Mortality Conferences (16)

•Narrative/Storytelling (11)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (516)

•Health Care Executives and Administrators (683)

•Non-Health Care Professionals (246)

•Patients (37)

Setting of Care

•Hospitals (471)

•Psychiatric Facilities (4)

•Residential Facilities (15)

•Ambulatory Care (80)

•Outpatient Surgery (6)

•Patient Transport (10)

1 - 20 of 850

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STUDY

Nursing home error and level of staff credentials.

Scott-Cawiezell J, Pepper GA, Madsen RW, Petroski G, Vogelsmeier A, Zellmer D. Clin Nurs Res. 2007;16:72-78.

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 errors during patient transitions into nursing homes: characteristics and association with patient harm.

Desai R, Williams CE, Greene SB, Pierson S, Hansen RA. Am J Geriatr Pharmacother. 2011;9:413-422.

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

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

The safety of warfarin therapy in the nursing home setting.

Gurwitz JH, Field TS, Radford MJ, et al. Am J Med. 2007;120:539-544.

STUDY

Nursing home administrators' opinions of the resident safety culture in nursing homes.

Castle NG, Handler S, Engberg J, Sonon K. Health Care Manage Rev. 2007;32:66-76.

STUDY

Assessment of adverse drug events among patients in a tertiary care medical center.

Johnston PE, France DJ, Byrne DW, et al. Am J Health Syst Pharm. 2006;63:2218-2227.

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.

REVIEW

Computerized physician order entry with clinical decision support in long-term care facilities: costs and benefits to stakeholders.

Subramanian S, Hoover S, Gilman B, Field TS, Mutter R, Gurwitz JH. J Am Geriatr Soc. 2007;55:1451-1457.

STUDY

ARV medication errors: experience of a community-based HIV specialty clinic and review of the literature.

Cocohoba J, Dong BJ. Hosp Pharm. 2007;42:720-728.

COMMENTARY

Using incident reporting to improve patient safety: a conceptual model.

Pronovost PJ, Holzmueller CG, Young J, et al. J Patient Saf. 2007;3:27-33.

STUDY

Adverse drug events in general practice patients in Australia.

Miller GC, Britt HC, Valenti L. Med J Aust. 2006;184:321-324.

NEWSPAPER/MAGAZINE ARTICLE

Multiple latent failures align to allow a serious drug interaction to harm a patient.

ISMP Medication Safety Alert! Acute Care Edition. May 5, 2011;16:1-3.

STUDY

The effect of a rapid response team on major clinical outcome measures in a community hospital.

Dacey MJ, Mirza ER, Wilcox V, et al. Crit Care Med. 2007;35:2076-2082.

STUDY

Ambulatory care adverse events and preventable adverse events leading to a hospital admission.

Woods DM, Thomas EJ, Holl JL, Weiss KB, Brennan TA. Qual Saf Health Care. 2007;16:127-131.

STUDY

Adverse drug reactions and therapeutic errors in older adults: a hazard factor analysis of poison center data.

Cobaugh DJ, Krenzelok EP. Am J Health Syst Pharm. 2006;63:2228-2234.

STUDY

National surveillance of emergency department visits for outpatient adverse drug events.

Budnitz DS, Pollock DA, Weidenbach KN, et al. JAMA. 2006;296:1858-1866.

STUDY

Risk models to improve safety of dispensing high-alert medications in community pharmacies.

Cohen MR, Smetzer JL, Westphal JE, Comden SC, Horn DM. J Am Pharm Assoc. 2012;52:584-602.

STUDY

The safety of hospital stroke care.

Holloway RG, Tuttle D, Baird T, Skelton WK. Neurology. 2007;68:550-555.

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