AHRQ Patient Safety Network

The Collection > Active Errors

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Safety Target

•Device-related Complications (64)

•Diagnostic Errors (151)

•Identification Errors (76)

•Discontinuities, Gaps, and Hand-Off Problems (119)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (425)

•Medical Complications (78)

•Nonsurgical Procedural Complications (37)

•Surgical Complications (140)

•Transfusion Complications (8)

•Psychological and Social Complications (40)

Origin/Sponsor

•Africa (1)

•Asia (17)

•Australia and New Zealand (28)

•Central and South America (5)

Resource Types

•Clinical Guideline (2)

•Journal Article (675)

•Legislation/Regulation (7)

•Meeting/Conference (3)

•Newspaper/Magazine Article (165)

•Press Release/Announcement (11)

•Special or Theme Issue (7)

•Tools/Toolkit (5)

•Web Resource (12)

•Grant (1)

Error Types
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Active Errors

•Noncognitive Errors ("Slips & Lapses") (108)

•Cognitive Errors ("Mistakes") (134)

Approach to Improving Safety

•Quality Improvement Strategies (226)

•Legal and Policy Approaches (112)

•Error Reporting and Analysis (250)

•Communication Improvement (268)

•Human Factors Engineering (216)

•Teamwork (41)

•Specialization of Care (44)

•Logistical Approaches (57)

•Culture of Safety (70)

•Technologic Approaches (216)

•Education and Training (210)

Clinical Areas

•Allied Health Services (7)

Target Audience

•Health Care Providers (739)

•Health Care Executives and Administrators (637)

•Non-Health Care Professionals (299)

•Patients (112)

Setting of Care

•Hospitals (635)

•Psychiatric Facilities (4)

•Residential Facilities (15)

•Ambulatory Care (125)

•Outpatient Surgery (16)

•Patient Transport (12)

1 - 20 of 930

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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.

NEWSPAPER/MAGAZINE ARTICLE

Misprogramming PCA concentration leads to dosing errors.

ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors occurring with the use of bar-code administration technology.

PA-PSRS Patient Saf Advis. December 2008;5:122-126.

NEWSPAPER/MAGAZINE ARTICLE

Epidural-IV route mix-ups: reducing the risk of deadly errors.

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

STUDY

Medication safety initiative in reducing medication errors.

Nguyen EE, Connolly PM, Wong V. J Nurs Care Qual. 2010;25:224-230.

REVIEW

Bar code technology and medication administration error.

Young J, Slebodnik M, Sands L. J Patient Saf. 2010;6;115-120.

COMMENTARY

ISMP medication error report analysis.

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

STUDY

Effect of bar-code technology on the safety of medication administration.

Poon EG, Keohane CA, Yoon CS, et al. N Engl J Med. 2010;362:1698-1707.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:191-195.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2012.

COMMENTARY

Learning accountability for patient outcomes.

Pronovost PJ. JAMA. 2010;304:204-205.

STUDY

Bar-code verification: reducing but not eliminating medication errors.

Henneman PL, Marquard JL, Fisher DL, et al. J Nurs Adm. 2012;42:562-566.

NEWSPAPER/MAGAZINE ARTICLE

Design for reliability: barcoded medication administration.

Hayden AC, Lanoue ET, Still CJ. Patient Saf Qual Healthc. July/August 2011;8:12-20.

STUDY

Bar-code technology for medication administration: medication errors and nurse satisfaction.

Fowler SB, Sohler P, Zarillo DF. MedSurg Nursing. 2009;18:103-110.

NEWSPAPER/MAGAZINE ARTICLE

Latest heparin fatality speaks loudly—what have you done to stop the bleeding?

ISMP Medication Safety Alert! April 8, 2010;15:1-3.

BOOK/REPORT

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.

Toft B. London, England: Department of Health; 2001.

REVIEW

Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002-2008.

Roughead EE, Semple SJ. Aust New Zealand Health Policy. 2009;6:18.

STUDY

The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.

Trbovich PL, Pinkney S, Cafazzo JA, Easty AC. Qual Saf Health Care. 2010;19:430-434.

COMMENTARY

Implementing a safe and reliable process for medication administration.

Richardson B, Bromirski B, Hayden A. Clin Nurse Spec. 2012;26:169-176.

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