AHRQ Patient Safety Network

The Collection > Error Analysis

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Safety Target

•Device-related Complications (27)

•Diagnostic Errors (84)

•Identification Errors (15)

•Discontinuities, Gaps, and Hand-Off Problems (62)

•Fatigue and Sleep Deprivation (10)

•Medication Safety (261)

•Medical Complications (60)

•Nonsurgical Procedural Complications (18)

•Surgical Complications (84)

•Transfusion Complications (4)

•Psychological and Social Complications (28)

Origin/Sponsor

•Asia (18)

•Australia and New Zealand (31)

•Central and South America (3)

Resource Types

•Journal Article (691)

•Legislation/Regulation (4)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (57)

•Press Release/Announcement (3)

•Special or Theme Issue (6)

•Tools/Toolkit (9)

•Web Resource (9)

Error Types

•Epidemiology of Errors and Adverse Events (381)

•Active Errors (111)

•Latent Errors (63)

•Near Miss (22)

Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (71)

•Failure Mode Effects Analysis (30)

•Morbidity and Mortality Conferences (16)

•Narrative/Storytelling (15)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (514)

•Health Care Executives and Administrators (657)

•Non-Health Care Professionals (252)

•Patients (43)

Setting of Care

•Hospitals (499)

•Psychiatric Facilities (5)

•Residential Facilities (14)

•Ambulatory Care (79)

•Outpatient Surgery (8)

•Patient Transport (6)

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COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

STUDY

Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians.

Davidenko JM, Snyder LS. J Electrocardiol. 2007;40:450-457.

STUDY

Hospital workload and adverse events.

Weissman JS, Rothschild JM, Bendavid E, et al. Med Care. 2007;45:448-455.

STUDY

Factors influencing perioperative nurses' error reporting preferences.

Espin S, Regehr G, Levinson W, Baker GR, Biancucci C, Lingard L. AORN J. 2007;85:527-528, 530-532, 534-536, 539-543.

STUDY

Large-scale deployment of the Global Trigger Tool across a large hospital system: refinements for the characterisation of adverse events to support patient safety learning opportunities.

Good VS, Saldaña M, Gilder R, Nicewander D, Kennerly DA. BMJ Qual Saf. 2011;20:25-30.

COMMENTARY

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

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

STUDY

Outside case review of surgical pathology for referred patients: the impact on patient care.

Swapp RE, Aubry MC, Salomão DR, Cheville JC. Arch Pathol Lab Med. 2013;137:233-240.

STUDY

Impact of diagnosis-timing indicators on measures of safety, comorbidity, and case mix groupings from administrative data sources.

Naessens JM, Campbell CR, Berg B, Williams AR, Culbertson R. Med Care. 2007;45:781-788.

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

Cognitive errors detected in anaesthesiology: a literature review and pilot study.

Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Br J Anaesth. 2012;108:229-235.

STUDY

Attitudes toward medical device use errors and the prevention of adverse events.

Johnson TR, Tang X, Graham MJ, et al. Jt Comm J Qual Patient Saf. 2007;33:689-694.

REVIEW

Twenty-four/seven: a mixed-method systematic review of the off-shift literature.

de Cordova PB, Phibbs CS, Bartel AP, Stone PW. J Adv Nurs. 2012;68:1454-1468.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: when pharmacy is closed.

PA-PSRS Patient Saf Advis. March 2012;9:11-17.

STUDY

Impact of attending physician workload on patient care: a survey of hospitalists.

Michtalik HJ, Yeh H, Pronovost PJ, Brotman DJ. JAMA Intern Med. 2013;173:375-377.

STUDY

Exploring strategies for reducing hospital errors.

McFadden KL, Stock GN, Gowen CR III. J Healthc Manag. 2006;51:123-136.

COMMENTARY

Smart pumps: advanced capabilities and continuous quality improvement.

Vanderveen T. Patient Saf Quality Healthc. January/February 2007.

STUDY

Economic measurement of medical errors using a hospital claims database.

David G, Gunnarsson CL, Waters HC, Horblyuk R, Kaplan HS. Value Health. 2013;16:305-310.

STUDY

Smartphone use during inpatient attending rounds: prevalence, patterns and potential for distraction.

Katz-Sidlow RJ, Ludwig A, Miller S, Sidlow R. J Hosp Med. 2012;7:595-599.

STUDY

The rate and costs attributable to intravenous patient-controlled analgesia errors.

Meissner B, Nelson W, Hicks R, Sikirica V, Gagne J, Schein J. Hosp Pharm. 2009;44:312–324.

STUDY

Contemporary evidence about hospital strategies for reducing 30-day readmissions: a national study.

Bradley EH, Curry L, Horwitz LI, et al. J Am Coll Cardiol. 2012;60:607-614.

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