AHRQ Patient Safety Network

The Collection > Error Analysis

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Safety Target

•Device-related Complications (18)

•Diagnostic Errors (77)

•Identification Errors (12)

•Discontinuities, Gaps, and Hand-Off Problems (70)

•Fatigue and Sleep Deprivation (9)

•Medication Safety (221)

•Medical Complications (41)

•Nonsurgical Procedural Complications (10)

•Surgical Complications (87)

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•Book/Report (19)

•Journal Article (545)

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•Newspaper/Magazine Article (30)

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•Special or Theme Issue (5)

•Tools/Toolkit (7)

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Error Types

•Epidemiology of Errors and Adverse Events (369)

•Active Errors (85)

•Latent Errors (42)

•Near Miss (19)

Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (28)

•Failure Mode Effects Analysis (18)

•Morbidity and Mortality Conferences (9)

•Narrative/Storytelling (4)

Clinical Areas

•Allied Health Services (4)

•Medicine (456)

•Nursing (46)

•Pharmacy (95)

Target Audience

•Health Care Providers (400)

•Health Care Executives and Administrators (477)

•Non-Health Care Professionals (147)

•Patients (18)

Setting of Care

•Hospitals (368)

•Psychiatric Facilities (4)

•Residential Facilities (9)

•Ambulatory Care (68)

•Outpatient Surgery (5)

•Patient Transport (7)

1 - 20 of 617

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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

Prevalence of preventable medication-related hospitalizations in Australia: an opportunity to reduce harm.

Kalisch LM, Caughey GE, Barratt JD, et al. Int J Qual Health Care. 2012;24:239-249.

STUDY

Effectiveness of a community collaborative for eliminating the use of high-risk abbreviations written by physicians.

Leonhardt KK, Botticelli J. J Patient Saf. 2006;2:147-153.

COMMENTARY

The lost sponge: patient safety in the operating room.

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

STUDY

The impact of abbreviations on patient safety.

Brunetti L, Santell JP, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:576-583.

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

Discontinuity of chronic medications in patients discharged from the intensive care unit.

Bell CM, Rahimi-Darabad P, Orner AI. J Gen Intern Med. 2006;21:937-941.

STUDY

Adverse events detected by clinical surveillance on an obstetric service.

Forster AJ, Fung I, Caughey S, et al. Obstet Gynecol. 2006;108:1073-1083.

STUDY

Time of day effects on the incidence of anesthetic adverse events.

Wright MC, Phillips-Bute B, Mark JB, et al. Qual Saf Health Care. 2006;15:258-263.

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.

REVIEW

Prescribing safely for children.

Sinha Y, Cranswick NE. J Paediatrics Child Health. 2007;43:112–116.

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

Surgeon age and operative mortality in the United States.

Waljee JF, Greenfield LJ, Dimick JB, Birkmeyer JD. Ann Surg. 2006;244:353-362.

STUDY

Ability of practitioners to identify solid oral dosage tablets.

Schiff GD, Kim S, Seger AC, Bult J, Bates DW. Am J Health Syst Pharm. 2006;63:838-843.

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.

REVIEW

Fatal errors in nitrous oxide delivery.

Herff H, Paal P, von Goedecke A, Lindner KH, Keller C, Wenzel V. Anaesthesia. 2007;62:1202-1206.

STUDY

Patient safety and telephone medicine: some lessons from closed claim case review.

Katz HP, Kaltsounis D, Halloran L, Mondor M. J Gen Intern Med. 2008;23:517-522.

STUDY

Detecting adverse drug reactions on paediatric wards: intensified surveillance versus computerised screening of laboratory values.

Haffner S, von Laue N, Wirth S, Thurmann PA. Drug Saf. 2005;28:453-464.

STUDY

Potential medication dosing errors in outpatient pediatrics.

McPhillips HA, Stille CJ, Smith D, et al. J Pediatr. 2005;147:761-767.

STUDY

Impact of intensive care unit discharge time on patient outcome.

Priestap FA, Martin CM. Crit Care Med. 2006;34:2946-2951.

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