AHRQ Patient Safety Network

The Collection > Error Reporting

PATIENT SAFETY PRIMERS
Never Events
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Safety Target

•Device-related Complications (28)

•Diagnostic Errors (18)

•Identification Errors (24)

•Discontinuities, Gaps, and Hand-Off Problems (27)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (159)

•Medical Complications (73)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (65)

•Transfusion Complications (8)

•Psychological and Social Complications (39)

Origin/Sponsor

•Africa (1)

•Asia (17)

•Australia and New Zealand (32)

Resource Types

•Journal Article (399)

•Legislation/Regulation (12)

•Meeting/Conference (4)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (81)

•Press Release/Announcement (10)

•Special or Theme Issue (5)

•Tools/Toolkit (13)

•Web Resource (25)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (154)

•Active Errors (78)

•Latent Errors (37)

•Near Miss (31)

Approach to Improving Safety
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Error Reporting

•Governmental Reporting (53)

•Institutional Reporting (71)

•Nongovernmental Reporting (13)

•Patient Disclosure (112)

•Patient Complaints (42)

•Never Events (43)

Clinical Areas

•Allied Health Services (3)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (408)

•Health Care Executives and Administrators (517)

•Non-Health Care Professionals (288)

•Patients (92)

Setting of Care

•Hospitals (387)

•Psychiatric Facilities (4)

•Residential Facilities (14)

•Ambulatory Care (44)

•Outpatient Surgery (13)

•Patient Transport (4)

1 - 20 of 635

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BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2013.

BOOK/REPORT

Adverse Events in Hospitals: Overview of Key Issues.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470.

COMMENTARY

The partnership with patients: a call to action for leaders.

Denham CR. J Patient Saf. 2011;7:113-121.

BOOK/REPORT

Hospital Reporting Program.

Portland, OR: Oregon Patient Safety Commission.

MULTI-USE WEBSITE

HAC Posting on Hospital Compare.

Centers for Medicare & Medicaid Services.

BOOK/REPORT

Patient Safety in Canada: An Update.

Ottawa, ON, Canada: Canadian Institute for Health Information; August 14, 2007.

NEWSPAPER/MAGAZINE ARTICLE

NY Medicaid ups the ante: by refusing to pay for 14 'never events,' the nation's biggest Medicaid program could propel other states into action.

DerGurahian J. Mod Healthc. June 16, 2008;38:6.

BOOK/REPORT classic

Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090.

STUDY

Measurement for improvement: a survey of current practice in Australian public hospitals.

Brand CA, Tropea J, Ibrahim JE, et al. Med J Aust. 2008;189:35-40.

BOOK/REPORT

Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems.

Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2012. Report No. OEI-06-09-00092.

COMMENTARY

Financial incentives to promote health care quality: the hospital acquired conditions nonpayment policy.

Kavanagh KT. Soc Work Public Health. 2011;26:524-541.

BOOK/REPORT

2009 Utah Sentinel Events Data Report.

Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.

REVIEW

Inpatient fall prevention programs as a patient safety strategy: a systematic review.

Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Ann Intern Med. 2013;158(5 Pt 2):390-396.

BOOK/REPORT

Standing Up for Doctors, Speaking Out for Patients. Final Report.

London, UK: Health Policy & Economic Research Unit, British Medical Association Scotland; May 2010.

STUDY

Slow progress on meeting hospital safety standards: learning from the Leapfrog Group's efforts.

Moran J, Scanlon D. Health Aff (Millwood). 2013;32:27-35.

NEWSPAPER/MAGAZINE ARTICLE

Diagnostic error in acute care.

PA-PSRS Patient Saf Advis. 2010;7:76-86.

STUDY

Interpreting adverse drug reaction (ADR) reports as hospital patient safety incidents.

Davies EC, Green CF, Mottram DR, Pirmohamed M. Br J Clin Pharmacol. 2010;70:102-108.

BOOK/REPORT

Adverse Events in Hospitals: State Reporting Systems.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00471.

BOOK/REPORT

Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-08-00220.

SPECIAL OR THEME ISSUE

The safety and quality of health care: where are we now?

Med J Aust. 2006;184:S37-S72.

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