AHRQ Patient Safety Network

The Collection > Active Errors

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Safety Target

•Device-related Complications (59)

•Diagnostic Errors (134)

•Identification Errors (76)

•Discontinuities, Gaps, and Hand-Off Problems (105)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (381)

•Medical Complications (80)

•Nonsurgical Procedural Complications (34)

•Surgical Complications (140)

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•Psychological and Social Complications (47)

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•Africa (1)

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•Clinical Guideline (2)

•Journal Article (618)

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•Newspaper/Magazine Article (164)

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Error Types
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Active Errors

•Noncognitive Errors ("Slips & Lapses") (84)

•Cognitive Errors ("Mistakes") (109)

Approach to Improving Safety

•Quality Improvement Strategies (207)

•Legal and Policy Approaches (107)

•Error Reporting and Analysis (243)

•Communication Improvement (259)

•Human Factors Engineering (191)

•Teamwork (40)

•Specialization of Care (39)

•Logistical Approaches (53)

•Culture of Safety (64)

•Technologic Approaches (192)

•Education and Training (181)

Clinical Areas

•Allied Health Services (8)

Target Audience

•Health Care Providers (691)

•Health Care Executives and Administrators (608)

•Non-Health Care Professionals (278)

•Patients (113)

Setting of Care

•Hospitals (599)

•Psychiatric Facilities (5)

•Residential Facilities (15)

•Ambulatory Care (117)

•Outpatient Surgery (16)

•Patient Transport (12)

1 - 20 of 868

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STUDY

Ambulance personnel perceptions of near misses and adverse events in pediatric patients.

Cushman JT, Fairbanks RJ, O'Gara KG, et al. Prehosp Emerg Care. 2010;14:477-484.

NEWSPAPER/MAGAZINE ARTICLE

Too many abandon the "second victims" of medical errors.

ISMP Medication Safety Alert! Acute Care Edition. July 14, 2011;16:1-3.

COMMENTARY

Disclosing harmful medical errors to patients: tackling three tough cases.

Gallagher TH, Bell SK, Smith KM, Mello MM, McDonald TB. Chest. 2009;136:897-903.

NEWSPAPER/MAGAZINE ARTICLE

Program encourages reporting accidents waiting to happen: the Good Catch Awards.

McCook A. Anesthesiology News. Sept 2011;37:9.

STUDY

The many faces of error disclosure: a common set of elements and a definition.

Fein SP, Hilborne LH, Spiritus EM, et al. J Gen Intern Med. 2007;22:755-761.

COMMENTARY

Disclosing harmful pathology errors to patients.

Dintzis SM, Gallagher TH. Am J Clin Pathol. 2009;131:463-465.

COMMENTARY

Anatomy of an incident disclosure: the importance of dialogue.

Iedema R, Allen S. Jt Comm J Qual Patient Saf. 2012;38:435-442.

BOOK/REPORT classic

When Things Go Wrong: Responding to Adverse Events.

A Consensus Statement of the Harvard Hospitals. Burlington: Massachusetts Coalition for the Prevention of Medical Errors; 2006.

STUDY

Explaining ethnic disparities in patient safety: a qualitative analysis.

Suurmond J, Uiters E, De Bruijne MC, Stronks K, Essink-Bot ML. Am J Public Health. 2010;100 (suppl 1):S113-117.

NEWSPAPER/MAGAZINE ARTICLE

Beware of basal opioid infusions with PCA therapy.

ISMP Medication Safety Alert! Acute Care Edition. March 12, 2009;14:1-3.

COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

COMMENTARY

Back to Basics

Hellman R. AHRQ WebM&M [serial online]. March 2007.

BOOK/REPORT

Second Victim: Error, Guilt, Trauma, and Resilience.

Dekker S. Boca Raton, FL: CRC Press; 2013. ISBN: 9781466583412.

BOOK/REPORT classic

The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives.

Maxfield D, Grenny J, Lavandero R, Groah L. Provo, UT: VitalSmarts; 2011.

COMMENTARY

In Conversation with...Sorrel King

AHRQ WebM&M [serial online]. March 2007.

COMMENTARY

The competent surgeon: individual accountability in the era of "systems" failure.

Whittemore AD. Ann Surg. 2009;250:357-362.

STUDY

Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and influencing factors.

Matlow AG, Moody L, Laxer R, Stevens P, Goia C, Friedman JN. Arch Dis Child. 2010;95:286-290.

NEWSPAPER/MAGAZINE ARTICLE

Drug shortages: national survey reveals high level of frustration, low level of safety.

ISMP Medication Safety Alert! Acute Care Edition. September 23, 2010;15,1-6.

STUDY

French national survey of inpatient adverse events prospectively assessed with ward staff.

Michel P, Quenon JL, Djihoud A, Tricaud-Vialle S, de Sarasqueta AM. Qual Saf Health Care. 2007;16:369-377.

NEWSPAPER/MAGAZINE ARTICLE

Proper positioning of pharmacy label on Hospira PCA vials will avoid interference with scanning.

ISMP Medication Safety Alert! Acute Care Edition. August 14, 2008;13:1-3.

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