AHRQ Patient Safety Network

The Collection > Active Errors

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Safety Target

•Device-related Complications (63)

•Diagnostic Errors (129)

•Identification Errors (71)

•Discontinuities, Gaps, and Hand-Off Problems (99)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (424)

•Medical Complications (72)

•Nonsurgical Procedural Complications (36)

•Surgical Complications (139)

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•Psychological and Social Complications (34)

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•Africa (2)

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•Clinical Guideline (2)

•Journal Article (640)

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•Newspaper/Magazine Article (160)

•Press Release/Announcement (14)

•Special or Theme Issue (5)

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Error Types
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Active Errors

•Noncognitive Errors ("Slips & Lapses") (87)

•Cognitive Errors ("Mistakes") (107)

Approach to Improving Safety

•Quality Improvement Strategies (209)

•Legal and Policy Approaches (101)

•Error Reporting and Analysis (262)

•Communication Improvement (247)

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•Technologic Approaches (207)

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Clinical Areas

•Allied Health Services (6)

•Medicine (680)

•Nursing (94)

•Pharmacy (150)

Target Audience

•Health Care Providers (708)

•Health Care Executives and Administrators (655)

•Non-Health Care Professionals (273)

•Patients (104)

Setting of Care

•Hospitals (580)

•Psychiatric Facilities (3)

•Residential Facilities (14)

•Ambulatory Care (117)

•Outpatient Surgery (17)

•Patient Transport (12)

1 - 20 of 891

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STUDY

Listen carefully: the risk of error in spoken medication orders.

Lambert BL, Dickey LW, Fisher WM, et al. Soc Sci Med. 2010;70:1599-1608.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:282-287.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2008;43:696–698.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:288-292.

COMMENTARY

Dealing honestly with an honest mistake.

Liang NL, Herring ME, Bush RL. J Vasc Surg. 2010;51:494-495.

PRESS RELEASE/ANNOUNCEMENT

Medication errors resulting from confusion between risperidone (Risperdal) and ropinirole (Requip).

MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; June 13, 2011.

STUDY

A comparison of voluntarily reported medication errors in intensive care and general care units.

Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:937-938, 945.

STUDY

Wrong-site craniotomy: analysis of 35 cases and systems for prevention.

Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473.

STUDY

Origins of and solutions for neonatal medication-dispensing errors.

Sauberan JB, Dean LM, Fiedelak J, Abraham JA. Am J Health Syst Pharm. 2010;67:49-57.

STUDY

Identifying and reducing medication errors in psychiatry: creating a culture of safety through the use of an adverse event reporting mechanism.

Jayaram G, Doyle D, Steinwachs D, Samuels J. J Psychiatr Pract. 2011;17:81–88.

STUDY

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.

NEWSPAPER/MAGAZINE ARTICLE

Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment.

ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Preventing catheter/tubing misconnections: much needed help is on the way.

ISMP Medication Safety Alert! Acute Care Edition. July 15, 2010;15:1-2.

COMMENTARY

Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine?

Reddy GK, Brown B, Nanda A. Clin Neurol Neurosurg. 2011;113:68-71.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:18-21.

NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

ISMP Medication Safety Alert! Acute Care Edition. May 3, 2007;12:1-2.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:405-406.

STUDY

What’s past is prologue: organizational learning from a serious patient injury.

Tamuz M, Franchois KE, Thomas EJ. Safety Sci. 2011;49:75-82.

NEWSPAPER/MAGAZINE ARTICLE

Fatal outcome after inadvertent injection of topical epinephrine.

ISMP Medication Safety Alert! Acute Care Edition. March 26, 2009;14:1-2.

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