Strategies for improving patient safety: linking task type to error type.

Elizabeth Andersson Mattox

Commentary

Strategies for improving patient safety: linking task type to error type.

February 22, 2012

Mattox EA. Crit Care Nurse. 2012;32(1):52-78.

View more articles from the same authors.

This commentary discusses types of errors associated with specific nursing tasks to illustrate how cognitive factors can affect safety.

PubMed citation

Available at

Related Resources From the Same Author(s)

Medical devices and patient safety.

August 22, 2012

Active-shooter response at a health care facility.

September 19, 2018

Drug shortages: effect on parenteral nutrition therapy.

March 21, 2018

Suicide as an incident of severe patient harm: a retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective.

March 31, 2021

Learning from incident reporting? Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care.

December 9, 2020

Worldwide incidence of surgical site infections in general surgical patients: a systematic review and meta-analysis of 488,594 patients.

December 8, 2021

Six major steps to make investigations of suicide valuable for learning and prevention.

November 2, 2022

Reasons for bias in ambulance clinicians' assessments of non-conveyed patients: a mixed-methods study.

May 25, 2022

High rate of implementation of proposed actions for improvement with the Healthcare Failure Mode Effect Analysis method: evaluation of 117 analyses.

April 22, 2015

Stand-alone artificial intelligence for breast cancer detection in mammography: comparison with 101 radiologists.

March 27, 2019

Communication failure in the operating room.

November 3, 2010

Cost of illness of patient-reported adverse drug events: a population-based cross-sectional survey.

July 24, 2013

Methods for assessing the preventability of adverse drug events: a systematic review.

January 30, 2005

Artificial intelligence-supported screen reading versus standard double reading in the Mammography Screening with Artificial Intelligence trial (MASAI): a clinical safety analysis of a randomised, controlled, non-inferiority, single-blinded, screening accuracy study.

November 15, 2023

Surgical team training: the Northwestern Memorial Hospital experience.

February 25, 2009

Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study.

July 22, 2020

Occupational therapy utilization in veterans with dementia: a retrospective review of root cause analyses of falls leading to adverse events.

April 6, 2022

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

Families as partners in hospital error and adverse event surveillance.

March 8, 2017

Crowding in the Emergency Department: Challenges for the Care of Children.

March 15, 2023

Structural racism and the COVID-19 experience in the United States.

July 7, 2021

Preventing home medication administration errors.

March 14, 2022

Complexity and challenges of the clinical diagnosis and management of Long COVID.

November 30, 2022

Statewide perinatal quality improvement, teamwork, and communication activities in Oklahoma and Texas.

July 26, 2023

Medical harm: patient perceptions and follow-up actions.

December 10, 2014

Impact of laws aimed at healthcare-associated infection reduction: a qualitative study.

September 30, 2015

Intended and unintended effects of large-scale adverse event disclosure: a controlled before-after analysis of five large-scale notifications.

April 29, 2015

The association of the nurse work environment and patient safety in pediatric acute care.

January 16, 2019

Evaluating the implementation and impact of a pharmacy technician-supported medicines administration service designed to reduce omitted doses in hospitals: a qualitative study.

June 12, 2019

Cardiac surgery errors: results from the UK National Reporting and Learning System.

February 16, 2011

Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association.

August 21, 2013

A multi-stakeholder consensus-driven research agenda for better understanding and supporting the emotional impact of harmful events on patients and families.

July 11, 2018

Randomized controlled evaluation of an insulin pen storage policy.

February 14, 2018

Racial and ethnic differences in emergency department diagnostic imaging at US Children's Hospitals, 2016-2019.

January 4, 2021

The influence of professional identity on how the receiver receives and responds to a speaking up message: a cross-sectional study.

March 29, 2023

"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses.

March 22, 2023

Identifying safety practices perceived as low value: an exploratory survey of healthcare staff in the United Kingdom and Australia.

March 8, 2023

Association between opioid tapering and subsequent health care use, medication adherence, and chronic condition control.

March 1, 2023

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

September 23, 2020

Expert consensus on currently accepted measures of harm.

September 9, 2020

Why do hospital prescribers continue antibiotics when it is safe to stop? Results of a choice experiment survey.

September 2, 2020

An examination of medical malpractice claims involving physician trainees.

August 19, 2020

Changing hospital organisational culture for improved patient outcomes: developing and implementing the Leadership Saves Lives intervention.

August 12, 2020

How accurately do older adult emergency department patients recall their medications?

August 12, 2020

Lessons learned from medical malpractice claims involving critical care nurses.

August 5, 2020

The safety of health care for ethnic minority patients: a systematic review.

July 29, 2020

Gender biases in estimation of others' pain.

April 28, 2021

Identifying errors and safety considerations in patients undergoing thrombolysis for acute ischemic stroke.

April 21, 2021

Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals.

April 14, 2021

Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals.

March 24, 2021

Enabling sustained communication with patients for safe and effective management of oral chemotherapy: a longitudinal ethnography.

March 17, 2021

Toward the development of the perfect medical team: critical components for adaptation.

March 17, 2021

The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients.

March 10, 2021

Extended work shifts and neurobehavioral performance in resident-physicians.

March 10, 2021

How does the environment influence consumers' perceptions of safety in acute mental health units? A qualitative study.

January 27, 2021

Virtual urgent care quality and safety in the time of Coronavirus.

January 20, 2021

Assessment of physician sleep and wellness, burnout, and clinically significant medical errors.

January 13, 2021

Conducting safety research safely: a policy-based approach for conducting research with peer review protected material.

January 13, 2021

Reducing inappropriate outpatient medication prescribing in older adults across electronic health record systems.

January 13, 2021

Identifying trigger concepts to screen emergency department visits for diagnostic errors.

December 16, 2020

Nurses' influence on consumers' experience of safety in acute mental health units: a qualitative study.

December 16, 2020

The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment.

July 14, 2021

Resident and family engagement in medication management in aged care facilities: a systematic review.

July 7, 2021

A systematic review of the effect of telepharmacy services in the community pharmacy setting on care quality and patient safety.

June 30, 2021

Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen-year period.

June 30, 2021

Older patients' engagement in hospital medication safety behaviours.

June 16, 2021

Interprofessional and intraprofessional communication about older people's medications across transitions of care.

May 26, 2021

Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit.

November 17, 2021

Survey of nurses' experiences applying The Joint Commission's medication management titration standards.

November 3, 2021

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care.

October 27, 2021

The effects of three consecutive 12-hour shifts on cognition, sleepiness, and domains of nursing performance in day and night shift nurses: a quasi-experimental study.

October 20, 2021

Factors associated with potentially missed acute deterioration in primary care: cohort study of UK general practices.

October 20, 2021

Safety events impacting hospitalized patients following motor vehicle crashes: a qualitative study of reports from Pennsylvania hospitals.

October 6, 2021

Physician task load and the risk of burnout among US physicians in a national survey.

December 2, 2020

Keeping patients at risk for self-harm safe in the emergency department: a protocolized approach.

December 2, 2020

I-PASS illness diversity identifies patients at risk for overnight clinical deterioration.

December 2, 2020

Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services national health policy.

November 25, 2020

Computer-based simulation to reduce EHR-related chemotherapy ordering errors.

November 18, 2020

Safer prescribing for hospitalized older adults with an electronic health records‐based prescribing context.

October 28, 2020

Process failures that increase the risk of infection through respiratory droplets: a study of patient safety events reported by hospitals across Pennsylvania.

October 7, 2020

The morbidity and mortality conference: opportunities for enhancing patient safety.

February 9, 2022

A safety maturity model for technology-induced errors.

February 9, 2022

Using smart IV infusion pumps outside of patient rooms.

February 2, 2022

Indication alerts to improve problem list documentation.

January 26, 2022

Potentially inappropriate prescribing and its associations with health-related and system-related outcomes in hospitalised older adults: a systematic review and meta-analysis.

January 19, 2022

Racial and ethnic differences in emergency department pain management of children with fractures.

April 22, 2020

Communicating certainty in pathology reports: interpretation differences among staff pathologists, clinicians, and residents in a multicenter study.

December 22, 2021

Systematic review of the impact of physician implicit racial bias on clinical decision making.

May 5, 2017

Follow-up of abnormal screening mammograms among low-income ethnically diverse women: findings from a qualitative study.

December 8, 2008

An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting.

December 8, 2021

Nursing interventions to reduce medication errors in paediatrics and neonates: systematic review and meta-analysis.

December 8, 2021

Do patient engagement interventions work for all patients? A systematic review and realist synthesis of interventions to enhance patient safety.

September 15, 2021

Association of dose tapering with overdose or mental health crisis among patients prescribed long-term opioids.

August 25, 2021

From implementation to sustainment: a large-scale adverse event disclosure support program generated through embedded research in the Veterans Health Administration.

August 18, 2021

Personal formularies of primary care physicians across 4 health care systems.

August 4, 2021

Developing perioperative Covid-19 testing protocols to restore surgical services.

July 22, 2020

A description of medical malpractice claims involving advanced practice providers.

July 15, 2020

Family support role in hospital rapid response teams: a scoping review.

April 13, 2022

How health systems decide to use artificial intelligence for clinical decision support.

April 6, 2022

Effects of state opioid prescribing laws on use of opioid and other pain treatments among commercially insured U.S. adults.

March 30, 2022

Related Resources

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Implementation of peer messengers to deliver feedback: an observational study to promote professionalism in nursing.

January 18, 2023

Annual Perspective

Annual Perspective: Topics in Medication Safety

March 31, 2022

Understanding patient safety and quality outcome data.

March 20, 2019

Targeting the fear of safety reporting on a unit level.

March 20, 2019

Learning from tragedy: the Julia Berg story.

December 12, 2018

Impact of nurse peer review on a culture of safety.

October 3, 2018

Guideline implementation: team communication.

September 12, 2018

'Cyberloafing' in health care: a real risk to patient safety.

September 5, 2018

Making an infusion error: the second victims of infusion therapy-related medication errors.

May 30, 2018

Realist synthesis of intentional rounding in hospital wards: exploring the evidence of what works, for whom, in what circumstances and why.

May 16, 2018

Medication errors involving nursing students: a systematic review.

February 7, 2018

Taking bullying out of health care: a patient safety imperative.

January 10, 2018

Nurses' clinical reasoning practices that support safe medication administration: an integrative review of the literature.

January 10, 2018

Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action.

December 6, 2017

Impact of interruptions, distractions, and cognitive load on procedure failures and medication administration errors.

July 19, 2017

Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices.

June 28, 2017

Exploring the experience of nurse practitioners who have committed medical errors: a phenomenological approach.

June 21, 2017

Evaluating situation awareness: an integrative review.

May 10, 2017

Nursing interruptions in a trauma intensive care unit: a prospective observational study.

May 3, 2017

Burnout mediates the association between depression and patient safety perceptions: a cross-sectional study in hospital nurses.

April 26, 2017

A work systems analysis approach to understanding fatigue in hospital nurses.

April 5, 2017

Promoting civility in the OR: an ethical imperative.

March 8, 2017

Opioids for pain management in older adults: strategies for safe prescribing.

February 22, 2017

Separate medication preparation rooms reduce interruptions and medication errors in the hospital setting: a prospective observational study.

February 15, 2017

Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios.

December 7, 2016

Recognising and responding to 'cutting corners' when providing nursing care: a qualitative study.

October 12, 2016

Organisational strategies to implement hospital pressure ulcer prevention programmes: findings from a national survey.

September 21, 2016

Health care worker fatigue.

September 21, 2016

Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: a root cause analysis of unplanned ICU admissions.

September 7, 2016

See More About The Topic

Strategies for improving patient safety: linking task type to error type.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Strategies for improving patient safety: linking task type to error type.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site