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 58 results
Download Selected Citations

Show: 20 | 50 | 100

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.

Perspectives on Safety > Perspective

Errors and Near Misses: What Health Care Could Learn From Aviation

with commentary by Carl Macrae, PhD, Root Cause Analysis: What Have We Learned?, December 2016

This piece explores how strategies from aviation, such as just culture and monitoring technologies, can be applied in health care to improve patient safety.

Patient Safety Primers

Adverse Events, Near Misses, and Errors

The terms adverse events, near misses, and medical errors are used in patient safety to refer to events where patients were harmed (or easily could have been).

Journal Article > Commentary

Driving surgical quality using operative video.

O'Mahoney PRA, Yeo HL, Lange MM, Milsom JW. Surg Innov. 2016;23:337-340.

Although using video documentation while providing care is controversial, it has been shown to contribute to error and near miss analysis. This commentary describes how utilizing videos in operating rooms can enhance patient safety and clinician accountability.

Journal Article > Commentary

Learning from mistakes and near mistakes: using root cause analysis as a risk management tool.

Cerniglia-Lowensen J. J Radiol Nurs. 2015;34:4-7.

Root cause analysis has been promoted by The Joint Commission and other organizations as a failure analysis tool, though problems with its usefulness remain due to issues with implementation and sufficient follow-up. This commentary provides an overview of the process and uses a case study to illustrate its value as a safety improvement strategy.

Journal Article > Study

Doctors' experiences of adverse events in secondary care: the professional and personal impact.

Harrison R, Lawton R, Stewart K. Clin Med. 2014;14:585-590.

According to this survey study, physicians involved in adverse events experience personal and professional harm, and existing reporting practices are not helpful. These findings suggest that despite prior work, systems to address physician needs remain inadequate. Dr. Albert Wu discussed the second victim phenomenon in a past AHRQ WebM&M interview.

Journal Article > Study

Organizational and social-psychological conditions in healthcare and their importance for patient and staff safety. A critical incident study among doctors and nurses.

Eklöf M, Törner M, Pousette A. Safety Sci. 2014;70:211-221.

Through in-depth interviews with Swedish physicians and nurses, this study provides insights into some of the structural and psychosocial aspects that affect patient safety. Staff stress caused by work overload, lack of social support, and frustration with organizational management was felt to directly contribute to clinical mistakes and near misses.

Journal Article > Study

Patient safety in external beam radiotherapy—guidelines on risk assessment and analysis of adverse error-events and near misses: introducing the ACCIRAD project.

Malicki J, Bly R, Bulot M, et al. Radiother Oncol. 2014;112:194-198.

This survey study found that safety practices for managing external beam radiotherapy vary among European countries. As with other safety concerns, adverse events are under-reported to voluntary reporting systems and root cause analysis of such incidents does not routinely occur. These results have clear implications for designing the planned intervention to improve the safety of external beam radiotherapy.

Journal Article > Study

Uptake of quality-related event standards of practice by community pharmacies.

Boyle TA, Bishop AC, Overmars C, et al. J Pharm Pract. 2015;28:442-449.

This analysis of community pharmacy practices found that while most have reporting of medication errors and near misses in place, few establish improvement plans or apply systems approaches to address errors. This finding underscores the need to learn from events and implement changes to resolve safety issues.

Journal Article > Study

Economic evaluation of the impact of medication errors reported by US clinical pharmacists.

Samp JC, Touchette DR, Marinac JS, Kuo GM; American College of Clinical Pharmacy Practice-Based Research Network Collaborative. Pharmacotherapy. 2014;34:350-357.

This economic analysis estimated the cost per medication error as approximately $89. The authors point out that, unlike previous research, this study included errors that did not result in patient harm.

Book/Report

Journal of Quality Improvement in Healthcare, Second Edition.

Heilman J, ed. Albuquerque, NM: University of New Mexico; May 2013.

This publication outlines quality and safety improvement projects from one hospital's residency program, including efforts to enhance care transitions, reduce wait times, and increase reporting of near misses and adverse events.

Journal Article > Study

From the school of nursing quality and safety officer: nursing students' use of safety reporting tools and their perception of safety issues in clinical settings.

Cooper E. J Prof Nurs. 2013;29:109-116.

Nursing students were reluctant to voluntarily report errors and near misses they witnessed, according to a survey conducted by the institution's nursing quality and safety officer.

Newspaper/Magazine Article

Should you reveal nonharmful mistakes to patients?

Yasgur BS. Medscape Business of Medicine. December 6, 2012.

This article discusses the results of a survey to assess physicians' perceptions about acknowledging mistakes that did not harm patients.

Journal Article > Study

Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system.

Ford EC, Smith K, Harris K, Terezakis S. Med Phys. 2012;39:6968-6971.

Analysis of voluntarily reported errors in radiation therapy treatments resulted in systematic changes to treatment planning and delivery. After the system improvements were implemented, no similar errors occurred and multiple near misses were detected before patients were affected.

Cases & Commentaries

Wrong Turn through Colon: Misplaced PEG

  • Web M&M

Rachel Sorokin, MD, and Mitchell Conn, MD, MBA; August 2012

Admitted for treatment of congestive heart failure, an elderly man with a percutaneously placed gastric feeding tube began to have liters of watery stool daily. A tube check revealed that the tip of the feeding tube was in the colon and not the stomach.

Cases & Commentaries

Misleading Complaint

  • Web M&M

Krishan Soni, MD, MBA, and Gurpreet Dhaliwal, MD; July 2012

A man presented to the emergency department (ED) complaining of knee problems, and the triage nurse wrote down the chief complaint as "bilateral knee pain." The ED physician diagnosed a musculoskeletal injury and prepared to discharge him, but the patient was noticeably unsteady. Further examination and imaging revealed a subdural hematoma requiring urgent neurosurgical intervention.

Book/Report

Systematic Systems Analysis: A Practical Approach to Patient Safety Reviews.

Duchscherer C, Davies JM. Calgary, Alberta, Canada: Health Quality Council of Alberta; 2012.

Drawing from human factors and system analysis techniques, this guide describes an approach to identifying contributing factors after an adverse event or near miss. The three phases of the model focus on collecting information, analyzing data, and developing recommendations for improvement.

Book/Report

A Process for Rapid Learning: Sharing Experience When Things Go Wrong in Out of Hours Services.

Retford, Notts, UK: NHS Alliance; 2011.

This publication discusses an initiative to monitor errors and near misses in after-hours care in the United Kingdom and reviews lessons learned during its first year of implementation.

Journal Article > Study

Identification by families of pediatric adverse events and near misses overlooked by health care providers.

Daniels JP, Hunc K, Cochrane D, et al. CMAJ. 2012;184:29-34.

This study introduced a family-based system for reporting adverse events and discovered a different lens into potential safety issues.

Journal Article > Study

Reporting of hazards and near-misses in the ambulatory care setting.

Schnall R, Bakken S. J Nurs Care Qual. 2011;26:328-334.

This study reports on an initiative to encourage student nurses to voluntarily report errors and near misses encountered during ambulatory care rotations.

Back to Top