Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "Active Errors"

1 - 20 of 280 results
Download Selected Citations

Show: 20 | 50 | 100

Journal Article > Study

Operational failures and interruptions in hospital nursing.

Tucker AL, Spear SJ. Health Serv Res. 2006;41:643-662.

This study discovered that nurses experienced more than eight work system failures during an 8-hour shift. Investigators combined primary observation with interview and survey methods to understand the role work system failures play on nurse effectiveness. The most frequent failures identified involved medications, orders, supplies, staffing, and equipment. In addition to operational failures that delayed productivity, a large number of reported work interruptions contributed to the study findings. The authors advocate for continued efforts to differentiate between tactics taken by bedside nurses to prevent error with tactics that result from the system (eg, interruptions), which often put patients at risk for error.

Web Resource > Government Resource

National Comparative Audit of Blood Transfusion.

National Blood Service Hospitals.

This Web site includes reports from audits on compliance with blood transfusion guidelines in the United Kingdom.

Patient Safety Primers

Patient Safety 101

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Journal Article > Review

The global burden of diagnostic errors in primary care.

Singh H, Schiff GD, Graber ML, Onakpoya I, Thompson MJ. BMJ Qual Saf. 2017;26:484-494.

The need to improve diagnosis is gaining international recognition. This review summarizes the literature on diagnostic error in primary care and recommends policy and research strategies to prioritize changes needed to enhance diagnostic safety globally.

Journal Article > Commentary

Improving the communication between teams managing boarded patients on a surgical specialty ward.

Puvaneswaralingam S, Ross D. BMJ Qual Improv Rep. 2016;5.

Boarding patients as they transfer between wards can compromise patient safety. This commentary reviews how an otolaryngology ward implemented a simple cognitive aid to improve patient record review, information sharing, and team communication. The authors report the results of the project and how they intend to use plan-do-study-act cycles to refine the process.

Journal Article > Study

Comparison of accuracy of physical examination findings in initial progress notes between paper charts and a newly implemented electronic health record.

Yadav S, Kazanji N, Narayan KC, et al. J Am Med Inform Assoc. 2017;24:140-144.

Compared to paper charts, electronic health records offer safety benefits for physician documentation including better availability and legibility. However, electronic documentation introduces new concerns, such as copy-and-paste practices (which can perpetuate errors) and lack of diagnostic reasoning in electronic notes. This study compared physical exam documentation in initial physician progress notes before and after implementation of an electronic health record. Investigators found more inaccuracies in electronic notes, but more errors of omission in paper charts. Trainee physicians' documentation had fewer errors in both paper and electronic formats. The authors recommend that hospitals discourage copied notes and encourage accurate documentation at the time of the patient encounter. The importance of the physical examination itself was discussed in a PSNet interview with Dr. Abraham Verghese.

Journal Article > Study

Radiologist-initiated double reading of abdominal CT: retrospective analysis of the clinical importance of changes to radiology reports.

Lauritzen PM, Andersen JG, Stokke MV, et al. BMJ Qual Saf. 2016;25:595-603.

Repeat interpretation of radiological images is known to yield more accurate diagnosis. Investigators interpreted more than 1000 abdominal CT scans twice and found clinically significant changes on the second read in 14% of cases. The authors suggest that using expert second radiology interpretation may enhance diagnostic accuracy.

Journal Article > Study

Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit.

Hughes KM, Goswami ES, Morris JL. J Pediatr Pharmacol Ther. 2015;20:453-461.

Drug shortages can result in safety consequences, as studies have shown a higher rate of treatment failure and increased adverse events associated with unavailability of first-line therapies. However, this study did not find any change in adverse events in pediatric intensive care unit patients during a shortage of commonly used sedatives and injectable opioid pain medications. The authors note that advance warning of the shortage and development of standardized algorithms for drug substitution may have mitigated the potential safety hazards.

Journal Article > Review

Role of cognition in generating and mitigating clinical errors.

Patel VL, Kannampallil TG, Shortliffe EH. BMJ Qual Saf. 2015;24:468-474.

Cognition has been recognized as a human factor that can contribute to failures in health care. This review examines cognitive aspects of human error that affect patient safety, methods to augment detection of flawed decision-making, and the potential for educational approaches like virtual reality simulation to train physicians to manage cognitive error once it occurs. A past AHRQ WebM&M interview with Dr. Pat Croskerry explored the role of cognition in medical error.

Journal Article > Commentary

Redesigning surgical decision making for high-risk patients.

Glance LG, Osler TM, Neuman MD. N Engl J Med. 2014;370:1379-1381.

Discussing communication weaknesses in surgery, this commentary examines how team-based decision making can contribute to safer and more patient-centered care in this setting, particularly for complex cases. The authors advocate for an enhanced safety culture to support better communication.

Journal Article > Study

Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample.

Newman-Toker DE, Moy E, Valente E, Coffey R, Hines AL. Diagnosis. 2014;1:155-166.

This observational study identified patients who visited the emergency department within 30 days prior to a stroke diagnosis. Nearly 13% of patients had a potential missed diagnosis, and more than 1% had a probable missed diagnosis of stroke. This study illustrates a novel approach to characterizing the incidence of missed diagnosis, an important and understudied patient safety problem.

Journal Article > Study

Characteristics of patients misdiagnosed with Alzheimer's disease and their medication use: an analysis of the NACC-UDS database.

Gaugler JE, Ascher-Svanum H, Roth DL, Fafowora T, Siderowf A, Beach TG. BMC Geriatr. 2013;13:137.

Using autopsy results, this study found that patients misdiagnosed with Alzheimer disease were more likely to be older, live alone, and have cardiovascular conditions, compared to accurately diagnosed individuals. Many misdiagnosed patients were taking inappropriate medications, which can have significant clinical and financial ramifications.

Newspaper/Magazine Article

To make hospitals less deadly, a dose of data.

Rosenberg T. New York Times. December 4, 2013.

Preventable adverse events may result in more harm than previously thought. Highlighting inconsistencies in publicly reported hospital safety data, this newspaper article explains how information is collected, analyzed, and presented by organizations such as Hospital Compare, Consumer Reports, and Leapfrog.

Journal Article > Study

Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before.

  • Classic

Vinden C, Nash DM, Rangrej J, et al. JAMA. 2013;310:1837-1841.

Considerable research has shown that sleep deprivation can affect cognitive performance, but the link between fatigue and clinical outcomes, particularly for surgeons, remains unclear. This case-control study sought to determine whether there was an association between sleep deprivation—defined as having performed an emergency procedure the night before—and complication rates for elective laparoscopic cholecystectomy. Although a prior single-institution study found increased complication rates for daytime procedures performed after operating the night before, this study used a much larger population-based database from Ontario, Canada and found no evidence of greater complications in patients whose surgeons had operated the night before. As duty hour restrictions for resident physicians appear to have had no effect on clinical outcomes, this study provides an argument against restricting practicing physician's duty hours.

Journal Article > Study

How well do we communicate? A comparison of intraoperative diagnoses listed in pathology reports and operative notes.

Talmon G, Horn A, Wedel W, Miller R, Stefonek A, Rinehart T. Am J Clin Pathol. 2013;140:651-657.

This study quantified communication errors between pathologists and surgeons regarding intraoperative tissue diagnoses. Although discrepancies between benign and malignant diagnoses were rare at about 0.3% of cases, the implications of these errors are profound.

Journal Article > Study

Readmission after delayed diagnosis of surgical site infection: a focus on prevention using the American College of Surgeons National Surgical Quality Improvement Program.

Gibson A, Tevis S, Kennedy G. Am J Surg. 2014;207:832-839.

The National Surgical Quality Improvement Program (NSQIP) was developed to monitor and enhance the quality of surgical care. This retrospective study used the NSQIP indicators to identify cases of surgical site infections. Researchers found that nearly 50% of patients were diagnosed following hospital discharge, and many of these infections led to readmissions. Patients who presented with a surgical site infection after discharge were less likely to smoke or have chronic cardiopulmonary illness. The authors suggest that closer postdischarge follow-up might have prevented some readmissions they identified. However, prior studies did not show a benefit to early follow-up. A past AHRQ WebM&M commentary discussed environmental safety in the operating room and its relationship to surgical site infections.

Journal Article > Study

Characteristics of paid malpractice claims settled in and out of court in the USA: a retrospective analysis.

Rubin JB, Bishop TF. BMJ Open. 2013;3:e002985.

This analysis of paid malpractice claims from the National Practitioner Data Bank found that the vast majority of claims were settled without a trial. The small number that did go to trial disproportionately involved physicians with prior malpractice claims.

Newspaper/Magazine Article

Misdiagnosis is more common than drug errors or wrong-site surgery.

Boodman SG. Washington Post. May 6, 2013.

This newspaper article discusses the pervasive problem of diagnostic errors and reveals insights from clinicians and patients on why they occur and how to prevent them.

Journal Article > Study

25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank.

Saber-Tehrani AS, Lee HW, Mathews SC, et al. BMJ Qual Saf. 2013;22:672-680.

The patient safety consequences of diagnostic errors have been receiving greater attention in the past few years, after being relatively neglected in the early period of the safety movement. The results of this study will likely add momentum to this "next frontier" in patient safety. The authors analyzed 25 years of closed malpractice claims from the National Practitioner Data Bank and found that diagnostic errors—primarily in the outpatient setting—were both the most common and the most costly (in terms of total payments) type of claim. Compared with other types of errors, diagnostic errors were more likely to result in serious patient harm or death. Although data from closed malpractice claims may not be representative of all error types, it is clear from this study that diagnostic errors account for a large proportion of preventable patient harm. Recent reviews have identified strategies to improve diagnostic accuracy at the individual clinician level and at the system level. The human costs of a fatal diagnostic error—for the patient and the clinician—were vividly illustrated in a recent graphic-novel style article.

Journal Article > Study

Accuracies of diagnostic methods for acute appendicitis.

Park JS, Jeong JH, Lee JI, Lee JH, Park JK, Moon HJ. Am Surg. 2013;79:101-106.

Comparison of diagnostic methods for acute appendicitis found that a strategy relying on ultrasonography as the initial diagnostic test would minimize diagnostic errors.

Back to Top