AHRQ Patient Safety Network

The Collection > Error Analysis

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•Device-related Complications (13)

•Diagnostic Errors (61)

•Identification Errors (17)

•Discontinuities, Gaps, and Hand-Off Problems (48)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (202)

•Medical Complications (48)

•Nonsurgical Procedural Complications (13)

•Surgical Complications (73)

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•Journal Article (496)

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•Newspaper/Magazine Article (26)

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Error Types

•Epidemiology of Errors and Adverse Events (370)

•Active Errors (79)

•Latent Errors (48)

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Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (30)

•Failure Mode Effects Analysis (14)

•Morbidity and Mortality Conferences (10)

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•Allied Health Services (3)

Target Audience

•Health Care Providers (416)

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Setting of Care

•Hospitals (355)

•Psychiatric Facilities (5)

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STUDY

Do panels vary when assessing intrapartum adverse events? The reproducibility of assessments by hospital risk management groups.

Kernaghan D, Penney GC. Qual Saf Health Care. 2006;15:359-362.

STUDY

A systematic approach to the identification and classification of near-miss events on labor and delivery in a large, national health care system.

Clark SL, Meyers JA, Frye DR, McManus K, Perlin JB. Am J Obstet Gynecol. 2012;207:441-445.

BOOK/REPORT

Learning from Investigations.

Healthcare Commission. London, England: Commission for Healthcare Audit and Inspection; 2008. ISBN: 9781845621636.

STUDY

Reevaluating recovery: perceived violations and preemptive interventions on emergency psychiatry rounds.

Cohen T, Blatter B, Almeida C, Patel VL. J Am Med Inform Assoc. 2007;14:312-319.

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.

COMMENTARY

Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems.

Hearns S, Shirley PJ. Emerg Med J. 2006;23:943-947.

STUDY

Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST).

Heddle NM, Fung M, Hervig T, et al; BEST Collaborative. Transfusion. 2012;52:1687-1695.

STUDY

Are the Agency for Healthcare Research and Quality obstetric trauma indicators valid measures of hospital safety?

Grobman WA, Feinglass J, Murthy S. Am J Obstet Gynecol. 2006;195:868-874.

STUDY

Using prospective clinical surveillance to identify adverse events in hospital.

Forster AJ, Worthington JR, Hawken S, et al. BMJ Qual Saf. 2011;20:756-763.

STUDY

Cause and effect analysis of closed claims in obstetrics and gynecology.

White AA, Pichert JW, Bledsoe SH, Irwin C, Entman SS. Obstet Gynecol. 2005;105:1031-1038.

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

The safety of hospital stroke care.

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

STUDY

Preventable adverse events in infants hospitalized with bronchiolitis.

McBride SC, Chiang VW, Goldmann DA, Landrigan CP. Pediatrics. 2005;116:603-608.

STUDY

An in-depth analysis of medication errors in hospitalized patients with HIV.

Snyder AM, Klinker K, Orrick JJ, Janelle J, Winterstein AG. Ann Pharmacother. 2011;45:459-468.

BOOK/REPORT

Quarterly National Reporting and Learning System Data Summary.

National Patient Safety Agency. London, UK: National Health Service.

COMMENTARY

Establishing a culture for patient safety - the role of education.

Milligan FJ. Nurse Educ Today. 2007;27:95-102.

REVIEW

Systematic review of medication errors in pediatric patients.

Ghaleb MA, Barber N, Franklin BD, Yeung VW, Khaki ZF, Wong IC. Ann Pharmacother. 2006;40:1766-1776.

STUDY

A series of anesthesia-related maternal deaths in Michigan, 1985-2003.

Mhyre JM, Riesner MN, Polley LS, Naughton NN. Anesthesiology. 2007;106:1096-1104.

NEWSPAPER/MAGAZINE ARTICLE

Maternity ward at Highland under fire from patients.

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

COMMENTARY

Hidden danger, obvious opportunity: error and risk in the management of cancer.

Munro AJ. Br J Radiol. 2007;80:955-966.

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