AHRQ Patient Safety Network

The Collection > Institutional Reporting

PATIENT SAFETY PRIMERS
Voluntary Patient Safety Event Reporting (Incident Reporting)

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Safety Target

•Device-related Complications (4)

•Diagnostic Errors (6)

•Identification Errors (3)

•Discontinuities, Gaps, and Hand-Off Problems (6)

•Fatigue and Sleep Deprivation (2)

•Medication Safety (44)

•Medical Complications (12)

•Nonsurgical Procedural Complications (4)

•Surgical Complications (5)

•Transfusion Complications (2)

•Psychological and Social Complications (7)

Origin/Sponsor

•Asia (5)

•Australia and New Zealand (5)

Resource Types

•Journal Article (109)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (13)

•Special or Theme Issue (2)

•Tools/Toolkit (1)

Error Types

•Epidemiology of Errors and Adverse Events (53)

•Active Errors (17)

•Latent Errors (7)

•Near Miss (11)

Approach to Improving Safety
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Institutional Reporting

Clinical Areas

•Allied Health Services (1)

•Medicine (84)

•Nursing (14)

•Pharmacy (12)

Target Audience

•Health Care Providers (75)

•Health Care Executives and Administrators (119)

•Non-Health Care Professionals (47)

•Patients (6)

Setting of Care

•Hospitals (103)

•Psychiatric Facilities (1)

•Residential Facilities (3)

•Ambulatory Care (6)

•Outpatient Surgery (1)

•Patient Transport (2)

1 - 20 of 131

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STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

STUDY

Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review.

Sari AB, Sheldon TA, Cracknell A, Turnbull A. BMJ. 2007;334;79.

STUDY

Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions.

Valenstein PN, Raab SS, Walsh MK. Arch Pathol Lab Med. 2006;130:1106-1113.

STUDY

The incidence and cost of unexpected hospital use after scheduled outpatient endoscopy.

Leffler DA, Kheraj R, Garud S, et al. Arch Intern Med. 2010;170:1752-1757.

STUDY

Learning from mistakes in New Zealand hospitals: what else do we need besides "no-fault"?

Soleimani F. N Z Med J. 2006;119:U2099.

STUDY

Paramedic self-reported medication errors.

Vilke GM, Tornabene SV, Stepanski B, et al. Prehosp Emerg Care. 2006;10:457-462.

COMMENTARY

Strategies to increase reporting of near misses and adverse events.

Conerly C. J Nurs Care Qual. 2007;22:102-106.

NEWSPAPER/MAGAZINE ARTICLE

Our long journey towards a safety-minded just culture. Part I: Where we've been.

ISMP Medication Safety Alert! Acute Care Edition. September 7, 2006;11:1-3.

STUDY

Evaluation of an anonymous system to report medical errors in pediatric inpatients.

Taylor JA, Brownstein D, Klein EJ, Strandjord TP. J Hosp Med. 2007;2:226-33.

STUDY

Physician perception of hospital safety and barriers to incident reporting.

Schectman JM, Plews-Ogan ML. Jt Comm J Qual Patient Saf. 2006;32:337-343.

STUDY

The need for organizational change in patient safety initiatives.

Anderson JG, Ramanujam R, Hensel D, Anderson MM, Sirio CA. Int J Med Inform. 2006;75:809-817.

STUDY

Rates and types of events reported to established incident reporting systems in two US hospitals.

Nuckols TK, Bell DS, Liu H, Paddock SM, Hilborne LH. Qual Saf Health Care. 2007;16:164-168.

COMMENTARY

Key Issues in Developing a Successful Hospital Safety Program

Whittington J. AHRQ WebM&M [serial online]. July 2006.

STUDY

Lessons learned: use of event reporting by nurses to improve patient safety and quality.

Hession-Laband E, Mantell P. J Pediatr Nurs. 2011;26:149-155.

STUDY

Getting doctors to report medical errors: project DISCLOSE.

King ES, Moyer DV, Couturie MJ, Gaughan JP, Shulkin DJ. Jt Comm J Qual Patient Saf. 2006;32:382-392.

COMMENTARY

Effective strategies to increase reporting of medication errors in hospitals.

Force MV, Deering L, Hubbe J, et al. J Nurs Adm. 2006;36:34-41.

STUDY

Evaluation of the contributions of an electronic web-based reporting system: enabling action.

Levtzion-Korach O, Alcalai H, Orav EJ, et al. J Patient Saf. 2009;5:9-15.

STUDY

Health care provider use of private sector internal error-reporting systems.

Roumm AR, Sciamanna CN, Nash DB. Am J Med Qual. 2005;20:304-312.

STUDY

The interrelationship of isolation precautions and adverse events in an acute care facility.

Spence MR, McQuaid M. Am J Infect Control. 2011;39:154-155.

STUDY

Patient safety event reporting in critical care: a study of three intensive care units.

Harris CB, Krauss MJ, Coopersmith CM, et al. Crit Care Med. 2007;35:1068-1076.

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