Narrow Results Clear All
- Review 1
- Study 9
- Slideset 1
- Book/Report 125
- Legislation/Regulation 5
- Newspaper/Magazine Article 13
- Newsletter/Journal 1
- Special or Theme Issue 1
- Toolkit 14
- Web Resource
- Grant 4
- Meeting/Conference 4
- Press Release/Announcement 23
- Communication Improvement 35
- Culture of Safety 44
Education and Training
- Students 2
Error Reporting and Analysis
- Never Events 13
- Error Reporting 145
- Human Factors Engineering 19
Legal and Policy Approaches
- Regulation 10
- Logistical Approaches 4
- Policies and Operations 2
Quality Improvement Strategies
- Benchmarking 11
- Research Directions 4
- Specialization of Care 2
- Teamwork 9
- Clinical Information Systems 10
- Transparency and Accountability 7
- Device-related Complications 17
- Diagnostic Errors 6
- Discontinuities, Gaps, and Hand-Off Problems 12
- Drug shortages 1
- Failure to rescue 1
- Fatigue and Sleep Deprivation 2
- Identification Errors 8
- Medical Complications 35
- Medication Errors/Preventable Adverse Drug Events 38
- MRI safety 2
- Nonsurgical Procedural Complications 5
- Overtreatment 1
- Psychological and Social Complications 12
- Surgical Complications 28
- Ambulatory Care 25
- General Hospitals 28
- Long-Term Care 7
- Outpatient Surgery 5
- Patient Transport 1
- Psychiatric Facilities 2
- Allied Health Services 1
- Internal Medicine 60
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- Nursing 8
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- Family Members and Caregivers 5
- Health Care Executives and Administrators 212
Health Care Providers
- Nurses 4
- Physicians 13
Non-Health Care Professionals
- Media 6
- Patients 44
- Australia and New Zealand 3
- Europe 59
- Canada 7
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 114
- United States Federal Government 143
Search results for "Error Reporting and Analysis"
- Web Resource
- Error Reporting and Analysis
Web Resource > Database/Directory
Agency for Healthcare Research and Quality.
The Patient Safety Organization (PSO) program seeks to gather and analyze nonidentifiable patient safety incident data to track concerns and reduce risks. This website provides data submitted from PSOs and other organizations in reports, chartbooks, and dashboards. These tools enable the wide dissemination of information to inform organizational improvement strategies.
Web Resource > Multi-use Website
Farnborough, Hampshire, UK.
Independent investigations examine system weaknesses in health care to inform improvement, reduce risk, and prevent harm. This organization collects information from individuals, groups, and organizations to identify and analyze incidents of substandard care and to proactively provide recommendations to reduce conditions that perpetuate failure in the National Health Service. Investigation areas include medication delivery for older patients and safe maternity care.
Newcastle Upon Tyne, UK: Care Quality Commission; October 2018.
This website provides access to an annual report that summarizes National Health Service hospital and social care performance across a range of care quality metrics at both the trust and service level. Most facilities were found to be improving their care quality and basic performance was found to be high. However the latest report found substantial gaps in mental health care delivery that affect the safety of patients.
Agency for Healthcare Research and Quality.
Washington, DC: Commission on Care; June 2016.
The Veterans Affairs health system has recently faced challenges associated with access and quality. Providing an assessment of the current and future state of the Veterans Health Administration, this report determined that care quality often meets or exceeds expectations but that quality varies from location to location. The authors outline recommendations for system improvements to ensure the safety of care delivery.
Web Resource > Government Resource
QualityNet. Centers for Medicare & Medicaid Services.
Hospital rating programs have received significant public attention, but concerns have been raised regarding their usefulness. This website provides resources to augment usability of this data including reports describing the methodology used by the Centers for Medicare and Medicaid Services to generate the information provided on the Hospital Compare website.
Mayer E, Flott K, Callahan R, Darzi A. London, UK: NIHR Imperial Patient Safety Translational Research Centre; 2016.
Incident reporting has achieved varying levels of success in encouraging transparency and facilitating system learning. This publication discusses reporting initiatives in the National Health Service and focuses on the importance of considering system purpose, user experience, data integrity, and feedback process to enhance reporting systems.
Washington, DC: United States Government Accountability Office; February 2016. Publication GAO-16-308.
Despite support for evidence-based medicine as a strategy to improve safety and quality, reliable use of best practices is lacking. Analyzing how six hospitals tried to implement evidence-based safety practices, this report identified in-house incident data use, practice selection, and implementation consistency as challenges to sustainable use of best practices.
Effective board governance of safe care: a (theoretically underpinned) cross-sectioned examination of the breadth and depth of relationships through national quantitative surveys and in-depth qualitative case studies.
Mannion R, Freeman T, Millar R, Davies H. Health Serv Deliv Res. 2016;4:1-165.
This mixed-methods analysis of four trusts in the National Health Service (NHS) found that evident board commitment and behavior supporting safety encourages staff to raise concerns that can lead to improvements. The authors suggest their results should help to inform hospital board training and recruitment efforts across the NHS.
Computerized Prescriber Order Entry Medication Safety (CPOEMS): Uncovering and Learning From Issues and Errors.
Brigham and Women's Hospital, Harvard Medical School, Partners HealthCare. Silver Spring, MD: US Food and Drug Administration; December 15, 2015.
Electronic prescribing, considered an opportunity to reduce medication errors, has been linked to problems unique to technology use. This white paper discusses the results of a multi-hospital effort to develop a process and tools to collect and analyze data related to search, display, and workflow issues associated with computerized provider order entry. The authors offer recommendations to enhance the safety of electronic prescribing, including standardizing drug names, minimizing the number of alerts, and designing better search functions.
Grant > Government Resource
AHRQ Health Services Research Projects: Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R01).
US Department of Health and Human Services. August 25, 2015. Program Announcement No. PA-15-339.
Department of Health. London, England: Crown Publishing; July 2015. ISBN: 9781474123716.
The National Health Service (NHS) has a history of sharing analyses of problems in its system. This publication contains the government response to three reports on system failures at the NHS: the Freedom to Speak Up review, the Investigating Clinical Incidents in the NHS report, and the Morecambe Bay Investigation. Common recommendations in the three reports included the need to support open discussions about what went wrong, learning from error, and a culture of safety.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; March 2019.
Ambulatory surgery centers are increasingly being used to provide surgical care. This survey seeks opinions from the field regarding safety culture in the ambulatory surgical center environment. The survey is presented with additional resources to help organizations assess their safety culture, including the results of a pilot program testing the survey and a user's guide. Ambulatory surgery centers that have used the survey can submit their data to the database from June 3–July 22.
Web Resource > Multi-use Website
American Society for Radiation Oncology and American Association of Physicists in Medicine.
Reporting of near misses and adverse events can provide a foundation for learning from error. This Web site supports an online portal facilitating incident reporting to enable data and experience analysis that will be used to inform development of guidelines and educational programs to promote safe practice in radiation oncology.
Washington, DC: National Quality Forum; 2016.
The value of current measures to track patient safety has been called into question. This technical report provides information about a consensus-driven initiative to evaluate the reliability of existing patient safety measures in tracking and assessing safety in hospitals, across various populations and settings. The related website offers resources related to the project history.
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. AHRQ Publication No. 14-0003.
Health care–associated infections (HAIs) are a known contributor to preventable patient harm. This AHRQ publication offers 19 papers that explore government-funded research into HAIs, including lessons learned from the design and implementation of prevention efforts along with projects that sought to detect and measure HAI incidents to determine risks. The report discusses specific infections, including clostridium difficile and methicillin-resistant staphylococcus aureus, as well as common conditions, such as central line-associated blood stream infections and catheter-associated urinary tract infections. A recent AHRQ WebM&M perspective reviews how infection prevention fits into a safety program.
Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.
Washington, DC: VA Office of the Inspector General; May 28, 2014. Report No. 14-02603-178.
The Veterans Health Administration has earned widespread praise for improving quality of care during the past decade, but this report by the Veterans Affairs (VA) Office of the Inspector General exposes serious problems within the Phoenix VA facility, which may be representative of system-wide issues with access to care. Even though the facility officially reported average wait times of only 24 days, the investigation found that veterans typically waited nearly 4 months for a new primary care appointment. This discrepancy was due to systematic manipulation of the scheduling system—more than 1700 patients had requested an appointment but were never enrolled on the waiting list for scheduling. Because wait times for primary care appointments were a VA quality metric, clinics likely resorted to gaming the system to appear to achieve their targets. The report indicates that evidence of inappropriate manipulation of the scheduling process has been found at many other VA facilities as well. The study did not formally address whether these delays in care directly led to deaths or preventable harm. An investigation of specific cases of deaths among patients who were waiting for appointments is ongoing and is expected to be released later this year.
McLeod M, Barber N, Franklin BD. National Quality Measures Clearinghouse: Expert Commentaries; March 10, 2014.
Strategies to prevent medication errors are an ongoing focus in patient safety. This expert commentary discusses challenges associated with tracking medication administration failures and recommends regular monitoring of medication delivery practices to avoid errors.
Kirkup B. London, UK: The Stationery Office; 2015. ISBN: 9780108561306.
Sharing information about large-scale investigations into failures can provide insights on factors that contribute to adverse clinical incidents. This report discusses an analysis of care delivered in the maternity unit of a National Health Service Trust between 2004 and 2013 which uncovered problems that were perpetuated due to failure to look into the initial event.
Meeting/Conference > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; November 2010.
This Web site provides videos of plenary addresses from the 2010 AHRQ Annual Conference, including presentations by Carolyn Clancy, MD, and Atul Gawande, MD.