AHRQ Patient Safety Network

The Collection > Error Analysis

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Safety Target

•Device-related Complications (27)

•Diagnostic Errors (86)

•Identification Errors (14)

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

•Fatigue and Sleep Deprivation (10)

•Medication Safety (274)

•Medical Complications (57)

•Nonsurgical Procedural Complications (18)

•Surgical Complications (87)

•Transfusion Complications (4)

•Psychological and Social Complications (27)

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•Asia (17)

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•Journal Article (676)

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•Newspaper/Magazine Article (56)

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•Special or Theme Issue (6)

•Tools/Toolkit (9)

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Error Types

•Epidemiology of Errors and Adverse Events (380)

•Active Errors (116)

•Latent Errors (60)

•Near Miss (22)

Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (56)

•Failure Mode Effects Analysis (28)

•Morbidity and Mortality Conferences (18)

•Narrative/Storytelling (11)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (513)

•Health Care Executives and Administrators (604)

•Non-Health Care Professionals (230)

•Patients (42)

Setting of Care

•Hospitals (492)

•Psychiatric Facilities (3)

•Residential Facilities (14)

•Ambulatory Care (83)

•Outpatient Surgery (7)

•Patient Transport (5)

1 - 20 of 806

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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

The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use.

Page RL 2nd, Ruscin JM. Am J Geriatr Pharmacother. 2006;4:297-305.

STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

STUDY

Reliability evaluation of the adapted National Coordinating Council Medication Error Reporting and Prevention (NCC MERP) index.

Snyder RA, Abarca J, Meza JL, Rothschild JM, Rizos A, Bates DW. Pharmacoepidemiol Drug Saf. 2007:16:1006-1013.

STUDY

Cost implications of actual and potential adverse events prevented by interventions of a critical care pharmacist.

Kopp BJ, Mrsan M, Erstad BL, Duby JJ. Am J Health Syst Pharm. 2007;64:2483-2487.

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

Predictors of medication errors among elderly hospital patients.

Picone DM, Titler MG, Dochterman J, et al. Am J Med Qual. 2008;23:115-127.

NEWSPAPER/MAGAZINE ARTICLE

A shortage of everything except errors: harm associated with drug shortages.

ISMP Medication Safety Alert! Acute Care Edition. April 19, 2012;17:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Supplementary Advisory: Results of the PA-PSRS Workgroup on Pharmacy Computer System Safety.

PA-PSRS Patient Saf Advis. May 2007;4(suppl 2):1-8.

STUDY

A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department.

Patanwala AE, Sanders AB, Thomas MC, et al. Ann Emerg Med. 2012;59:369-373.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: when pharmacy is closed.

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

STUDY

Nurses relate the contributing factors involved in medication errors.

Tang FI, Sheu SJ, Yu S, Wei IL, Chen CH. J Clin Nurs. 2007;16:447-457.

STUDY

Medication administration discrepancies persist despite electronic ordering.

FitzHenry F, Peterson JF, Arrieta M, Waitman LR, Schildcrout JS, Miller RA. J Am Med Inf Assoc. 2007;14:756-764.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:1148-1151.

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

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

Supratherapeutic dosing of acetaminophen among hospitalized patients.

Zhou L, Maviglia SM, Mahoney LM, et al. Arch Intern Med. 2012;172:1721-1728.

STUDY

Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular examinations for orthopedic trauma patients.

Tan EW, Ting BL, Jia XF, Skolasky RL, McFarland EG. Am J Med Qual. 2013;28:60-68.

STUDY

Rate, causes and reporting of medication errors in Jordan: nurses' perspectives.

Mrayyan MT, Shishani K, Al-Faouri I. J Nurs Manag. Sep 2007;15:659-670.

NEWSPAPER/MAGAZINE ARTICLE

Common cause analysis.

Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.

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