AHRQ Patient Safety Network

The Collection > Epidemiology of Errors and Adverse Events

PATIENT SAFETY PRIMERS
Never Events
Adverse Events after Hospital Discharge

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Safety Target

•Device-related Complications (68)

•Diagnostic Errors (106)

•Identification Errors (56)

•Discontinuities, Gaps, and Hand-Off Problems (163)

•Fatigue and Sleep Deprivation (28)

•Medication Safety (576)

•Medical Complications (191)

•Nonsurgical Procedural Complications (24)

•Surgical Complications (196)

•Transfusion Complications (13)

•Psychological and Social Complications (36)

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•Africa (4)

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•Australia and New Zealand (54)

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Resource Types

•Audiovisual (4)

•Book/Report (55)

•Clinical Guideline (1)

•Journal Article (1272)

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•Newspaper/Magazine Article (52)

•Press Release/Announcement (3)

•Special or Theme Issue (4)

•Tools/Toolkit (1)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (255)

•Legal and Policy Approaches (77)

•Error Reporting and Analysis (583)

•Communication Improvement (238)

•Human Factors Engineering (137)

•Teamwork (44)

•Specialization of Care (93)

•Logistical Approaches (106)

•Culture of Safety (96)

•Technologic Approaches (257)

•Education and Training (175)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (1035)

•Health Care Executives and Administrators (1104)

•Non-Health Care Professionals (415)

•Patients (63)

Setting of Care

•Hospitals (1047)

•Psychiatric Facilities (5)

•Residential Facilities (38)

•Ambulatory Care (170)

•Outpatient Surgery (21)

•Patient Transport (17)

1 - 20 of 1412

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STUDY

Temporal trends in rates of patient harm resulting from medical care.

Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. N Engl J Med. 2010;363:2124-2134.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: when pharmacy is closed.

PA-PSRS Patient Saf Advis. March 2012;9:11-17.

STUDY

Prescribing discrepancies likely to cause adverse drug events after patient transfer.

Boockvar KS, Liu S, Goldstein N, Nebeker J, Siu A, Fried T. Qual Saf Health Care. 2009;18:32-36.

REVIEW

Systematic review: association of shift length, protected sleep time, and night float with patient care, residents' health, and education.

Reed DA, Fletcher KE, Arora VM. Ann Intern Med. 2010;153:829-842.

STUDY

Impact of attending physician workload on patient care: a survey of hospitalists.

Michtalik HJ, Yeh H, Pronovost PJ, Brotman DJ. JAMA Intern Med. 2013;173:375-377.

NEWSPAPER/MAGAZINE ARTICLE

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

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

STUDY

Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy.

Waitman LR, Phillips IE, McCoy AB, et al. Jt Comm J Qual Patient Saf. 2011;37:326-332.

STUDY

A multidisciplinary approach to reduce central line–associated bloodstream infections.

McMullan C, Propper G, Schuhmacher C, et al. Jt Comm J Qual Patient Saf. 2013;39:61-69.

STUDY

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.

STUDY

Measuring adverse events and levels of harm in pediatric inpatients with the Global Trigger Tool.

Kirkendall ES, Kloppenborg E, Papp J, et al. Pediatrics. 2012;130:e1206-e1214.

STUDY

An objective study of the impact of the electronic medical record on outcomes in trauma patients.

Schenarts PJ, Goettler CE, White MA, Waibel BH. Am Surg. 2012;78:1249-1254.

STUDY

Determinants of patient-reported medication errors: a comparison among seven countries.

Lu CY, Roughead E. Int J Clin Pract. 2011;65:733-740.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2012.

Oakbrook Terrace, IL: The Joint Commission; September 2012.

NEWSPAPER/MAGAZINE ARTICLE

What drugs do you take? Hospitals seek to collect better data and prevent errors.

Landro L. Wall Street Journal (Eastern edition). May 23, 2006:D1. [reprinted on Post-Gazette.com]

NEWSPAPER/MAGAZINE ARTICLE

Follow ISMP guidelines to safeguard the design and use of automated dispensing cabinets (ADCs).

ISMP Medication Safety Alert! Acute Care Edition. February 12, 2009;14:1-4.

STUDY

The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II.

Leape LL, Brennan TA, Laird N, et al. N Engl J Med. 1991;324:377-384.

STUDY

Last orders: follow-up of tests ordered on the day of hospital discharge.

Ong MS, Magrabi F, Jones G, Coiera E. Arch Intern Med. 2012;172:1347-1349.

REVIEW

Improving patient handovers from hospital to primary care: a systematic review.

Hesselink G, Schoonhoven L, Barach P, et al. Ann Intern Med. 2012;157:417-428.

STUDY

Is patient safety improving? National trends in patient safety indicators: 1998–2007.

Downey JR, Hernandez-Boussard T, Banka G, Morton JM. Health Serv Res. 2012;47:414-430.

STUDY

Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction.

Salisbury AC, Reid KJ, Alexander KP, et al. Arch Intern Med. 2011;171:1646-1653.

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