AHRQ Patient Safety Network

The Collection > Error Analysis

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Safety Target

•Device-related Complications (11)

•Diagnostic Errors (55)

•Identification Errors (9)

•Discontinuities, Gaps, and Hand-Off Problems (44)

•Fatigue and Sleep Deprivation (11)

•Medication Safety (139)

•Medical Complications (28)

•Nonsurgical Procedural Complications (7)

•Surgical Complications (92)

•Transfusion Complications (1)

•Psychological and Social Complications (21)

Origin/Sponsor

•Asia (12)

•Australia and New Zealand (22)

•Central and South America (2)

Resource Types

•Journal Article (409)

•Legislation/Regulation (4)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (33)

•Press Release/Announcement (2)

•Special or Theme Issue (8)

•Tools/Toolkit (5)

•Web Resource (9)

Error Types

•Epidemiology of Errors and Adverse Events (206)

•Active Errors (82)

•Latent Errors (43)

•Near Miss (14)

Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (33)

•Failure Mode Effects Analysis (20)

•Morbidity and Mortality Conferences (6)

•Narrative/Storytelling (5)

Clinical Areas

•Allied Health Services (3)

•Medicine (346)

•Nursing (56)

•Pharmacy (45)

Target Audience

•Health Care Providers (379)

•Health Care Executives and Administrators (417)

•Non-Health Care Professionals (154)

•Patients (24)

Setting of Care

•Hospitals (304)

•Psychiatric Facilities (5)

•Residential Facilities (7)

•Ambulatory Care (38)

•Outpatient Surgery (6)

•Patient Transport (3)

1 - 20 of 501

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STUDY

Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work.

Nemeth C, O’Connor M, Klock PA, Cook R. Org Stud. 2006;27:1011-1035.

COMMENTARY

The lost sponge: patient safety in the operating room.

Grant-Orser A, Davies P, Singh SS. CMAJ. 2012;184:1275-1278.

STUDY

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

Sexton JB, Makary MA, Tersigni AR, et al. Anesthesiology. 2006;105:877-884.

STUDY

Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study.

van Klei WA, Hoff RG, van Aarnhem EE, et al. Ann Surg. 2012;255:44-49.

STUDY

Failures in communication and information transfer across the surgical care pathway: interview study.

Nagpal K, Arora S, Vats A, et al. BMJ Qual Saf. 2012;21:843-849.

STUDY

Computerized provider order entry implementation: no association with increased mortality rates in an intensive care unit.

Del Beccaro MA, Jeffries HE, Eisenberg MA, Harry ED. Pediatrics. 2006;118:290-295.

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.

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.

STUDY

"First, do no harm": balancing competing priorities in surgical practice.

Leung A, Luu S, Regehr G, Murnaghan ML, Gallinger S, Moulton CA. Acad Med. 2012;87:1368-1374.

MULTI-USE WEBSITE

Scottish Audit of Surgical Mortality.

Royal College of Physicians and Surgeons of Glasgow, 232-242 St Vincent Street, Glasgow, UK G2 5RJ.

STUDY

Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.

Hu YY, Arriaga AF, Roth EM, et al. Ann Surg. 2012;256:203-210.

STUDY

Risk factors associated with incorrect surgical counts.

Rowlands A. AORN J. 2012;96:272-284.

STUDY

Waking up the next morning: surgeons' emotional reactions to adverse events.

Luu S, Patel P, St-Martin L, et al. Med Educ. 2012;46:1179-1188.

STUDY

Potentially unintended discontinuation of long-term medication use after elective surgical procedures.

Bell CM, Bajcar J, Bierman AS, et al. Arch Intern Med. 2006;166:2525-2531.

STUDY

Surgical skill is predicted by the ability to detect errors.

Bann S, Khan M, Datta V, Darzi A. Am J Surg. 2005;189:412-415.

STUDY

Medication safety in the ambulatory chemotherapy setting.

Gandhi TK, Bartel SB, Shulman LN, et al. Cancer. 2005;104:2477-2483.

REVIEW

Retrieval of iatrogenic intravascular foreign bodies.

Schechter MA, O'Brien PJ, Cox MW. J Vasc Surg. 2013;57:276-281.

STUDY

Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error.

Goodman EJ, Haas AJ, Kantor GS. Int J Obstet Anesth. 2006;15:63-67.

COMMENTARY

PCA Overdose

Doyle DJ. AHRQ WebM&M [serial online]. July/August 2005.

STUDY

Fatality involving vinblastine overdose as a result of a complex medical error.

Klys M, Konopka T, Scislowski M, Kowalski P. Cancer Chemother Pharmacol. 2007;59:89-95.

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