AHRQ Patient Safety Network

The Collection > Error Analysis

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Safety Target

•Device-related Complications (29)

•Diagnostic Errors (93)

•Identification Errors (22)

•Discontinuities, Gaps, and Hand-Off Problems (68)

•Fatigue and Sleep Deprivation (12)

•Medication Safety (264)

•Medical Complications (64)

•Nonsurgical Procedural Complications (22)

•Surgical Complications (95)

•Transfusion Complications (6)

•Psychological and Social Complications (34)

Origin/Sponsor

•Africa (1)

•Asia (20)

•Australia and New Zealand (36)

•Central and South America (3)

Resource Types

•Journal Article (745)

•Legislation/Regulation (5)

•Meeting/Conference (1)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (56)

•Press Release/Announcement (3)

•Special or Theme Issue (9)

•Tools/Toolkit (10)

•Web Resource (10)

Error Types

•Epidemiology of Errors and Adverse Events (339)

•Active Errors (137)

•Latent Errors (81)

•Near Miss (25)

Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (100)

•Failure Mode Effects Analysis (47)

•Morbidity and Mortality Conferences (23)

•Narrative/Storytelling (22)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (581)

•Health Care Executives and Administrators (727)

•Non-Health Care Professionals (290)

•Patients (45)

Setting of Care

•Hospitals (530)

•Psychiatric Facilities (4)

•Residential Facilities (14)

•Ambulatory Care (77)

•Outpatient Surgery (6)

•Patient Transport (8)

1 - 20 of 900

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NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

ISMP Medication Safety Alert! Acute Care Edition. May 3, 2007;12:1-2.

STUDY

Diagnostic errors with inserted tubes, lines and catheters in children.

Fuentealba I, Taylor GA. Pediatr Radiol. 2012;42:1305-1315.

STUDY

Paid malpractice claims for adverse events in inpatient and outpatient settings.

Bishop TF, Ryan AK, Casalino LP. JAMA. 2011;305:2427-2431.

MEASUREMENT TOOL/INDICATOR

Tubing Misconnections Self Assessment for Healthcare Facilities.

Horsham, PA: Institute for Safe Medication Practices, Deerfield, IL: Baxter Healthcare; 2012.

STUDY

Venous thromboembolism after trauma: a never event?

Thorson CM, Ryan ML, Van Haren RM, et al. Crit Care Med. 2012;40:2967-2973.

COMMENTARY

Application of failure mode and effect analysis in a radiology department.

Thornton E, Brook OR, Mendiratta-Lala M, Hallett DT, Kruskal JB. Radiographics. 2011;31:281-293.

STUDY

Handoff communication between hospital and outpatient dialysis units at patient discharge: a qualitative study.

Reilly JB, Marcotte LM, Berns JS, Shea JA. Jt Comm J Qual Patient Saf. 2013;39:70-76.

STUDY

Wisdom through adversity: learning and growing in the wake of an error.

Plews-Ogan M, Owens JE, May NB. Patient Educ Couns. 2013;91:236-242.

STUDY

Challenges and opportunities to prevent transfusion errors: a Qualitative Evaluation for Safer Transfusion (QUEST).

Heddle NM, Fung M, Hervig T, et al; BEST Collaborative. Transfusion. 2012;52:1687-1695.

STUDY

Complexity of medication-related verbal orders.

Wakefield DS, Ward MM, Groath D, et al. Am J Med Qual. 2008;23:7-17.

STUDY

The safety of hospital stroke care.

Holloway RG, Tuttle D, Baird T, Skelton WK. Neurology. 2007;68:550-555.

COMMENTARY

Diagnostic errors—The next frontier for patient safety.

Newman-Toker DE, Pronovost PJ. JAMA. 2009;301:1060-1062.

STUDY

Quantitative assessment of workload and stressors in clinical radiation oncology.

Mazur LM, Mosaly PR, Jackson M, et al. Int J Radiat Oncol Biol Phys. 2012;83:e571-e576.

COMMENTARY

Safety strategies in an academic radiation oncology department and recommendations for action.

Terezakis SA, Pronovost P, Harris K, Deweese T, Ford E. Jt Comm J Qual Patient Saf. 2011;37:291-299.

COMMENTARY

Preventable errors in organ transplantation: an emerging patient safety issue?

Ison MG, Holl JL, Ladner D. Am J Transplant. 2012;12:2307-2312.

STUDY

Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data.

Nebeker JR, Yarnold PR, Soltysik RC, et al. Med Care. 2007;45(suppl 2):S81-S88.

NEWSPAPER/MAGAZINE ARTICLE

Events associated with the prescribing, dispensing, and administering of medication loading doses.

Carson SL, Gaunt MJ. PA-PSRS Patient Saf Advis. 2012;9:82-88.

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.

COMMENTARY

The concept of error and malpractice in radiology.

Pinto A, Brunese L, Pinto F, Reali R, Daniele S, Romano L. Semin Ultrasound CT MR. 2012;33:275-279.

COMMENTARY

Using the opportunity estimator tool to improve engagement in a quality and safety intervention.

Duval-Arnould J, Mathews SC, Weeks K, et al. Jt Comm J Qual Patient Saf. 2012;38:41-47.

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