AHRQ Patient Safety Network

The Collection > Error Reporting

PATIENT SAFETY PRIMERS
Never Events
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Safety Target

•Device-related Complications (34)

•Diagnostic Errors (26)

•Identification Errors (35)

•Discontinuities, Gaps, and Hand-Off Problems (29)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (217)

•Medical Complications (68)

•Nonsurgical Procedural Complications (18)

•Surgical Complications (81)

•Transfusion Complications (7)

•Psychological and Social Complications (45)

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•Asia (16)

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•Journal Article (505)

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•Newspaper/Magazine Article (96)

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•Special or Theme Issue (13)

•Tools/Toolkit (11)

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Error Types

•Epidemiology of Errors and Adverse Events (169)

•Active Errors (135)

•Latent Errors (38)

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Approach to Improving Safety
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Error Reporting

•Governmental Reporting (26)

•Institutional Reporting (72)

•Nongovernmental Reporting (17)

•Patient Disclosure (157)

•Patient Complaints (22)

•Never Events (30)

Clinical Areas

•Allied Health Services (5)

•Complementary and Alternative Medicine (2)

Target Audience

•Health Care Providers (507)

•Health Care Executives and Administrators (577)

•Non-Health Care Professionals (260)

•Patients (89)

Setting of Care

•Hospitals (358)

•Psychiatric Facilities (3)

•Residential Facilities (19)

•Ambulatory Care (57)

•Outpatient Surgery (13)

•Patient Transport (9)

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COMMENTARY

Medication errors related to product names.

Santell JP, Cousins DD. Jt Comm J Qual Patient Saf. 2005;31:649-654.

COMMENTARY

Dealing honestly with an honest mistake.

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

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.

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.

COMMENTARY

ISMP medication error report analysis.

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

STUDY

Characteristics of medication errors and adverse drug events in hospitals participating in the California Pediatric Patient Safety Initiative.

Takata GS, Taketomo CK, Waite S; for the California Pediatric Patient Safety Initiative. Am J Health Syst Pharm. 2008;65:2036-2044.

STUDY

Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after 1,946,831 operations in children.

Camp M, Chang DC, Zhang Y, Chrouser K, Colombani PM, Abdullah F. Arch Surg. 2010;145:1085-1090.

STUDY

The incidence and nature of prescribing and medication administration errors in paediatric inpatients.

Ghaleb MA, Barber N, Franklin BD, Wong ICK. Arch Dis Child. 2010;95:113-118.

NEWSPAPER/MAGAZINE ARTICLE

Generic drug names: fertile ground for errors?

Wynn P. Drug Topics Supplements. August 8, 2005.

STUDY

Repeat medication errors in nursing homes: contributing factors and their association with patient harm.

Crespin DJ, Modi AV, Wei D, et al. Am J Geriatr Pharmacother. 2010;8:258-270.

COMMENTARY classic

Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.

STUDY

Self-reported violations during medication administration in two paediatric hospitals.

Alper SJ, Holden RJ, Scanlon MC, et al. BMJ Qual Saf. 2012;21:408-415.

COMMENTARY

Between a rock and a hard place: disclosing medical errors.

Crone KG, Muraski MB, Skeel JD, Love-Gregory L, Ladenson JH, Gronowski AM. Clin Chem. 2006;52:1809-1814.

COMMENTARY

Using medical-error reporting to drive patient safety efforts.

Stow J. AORN J. 2006;84:406-408, 411-414, 417-420.

COMMENTARY

The Role of the Patient in Improving Patient Safety

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

STUDY

Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.

Lin MY, Hota B, Khan YM, et al; CDC Prevention Epicenter Program. JAMA. 2010;304:2035-2041.

STUDY

Inadvertent misadministration of meningococcal conjugate vaccine—United States, June–August 2005.

Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2006;55:1016-1017.

NEWSPAPER/MAGAZINE ARTICLE

Ding-a-ling-a-ling: ambulances can be dangerous places.

Meisel Z. Slate. November 8, 2005.

STUDY

Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.

Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.

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