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 (60)

•Diagnostic Errors (97)

•Identification Errors (51)

•Discontinuities, Gaps, and Hand-Off Problems (129)

•Fatigue and Sleep Deprivation (16)

•Medication Safety (480)

•Medical Complications (160)

•Nonsurgical Procedural Complications (24)

•Surgical Complications (183)

•Transfusion Complications (14)

•Psychological and Social Complications (25)

Origin/Sponsor

•Africa (4)

•Asia (30)

•Australia and New Zealand (56)

•Central and South America (7)

Resource Types

•Clinical Guideline (1)

•Journal Article (1058)

•Legislation/Regulation (4)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (25)

•Press Release/Announcement (2)

•Special or Theme Issue (2)

•Tools/Toolkit (1)

•Web Resource (11)

Error Types
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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (235)

•Legal and Policy Approaches (45)

•Error Reporting and Analysis (459)

•Communication Improvement (192)

•Human Factors Engineering (123)

•Teamwork (46)

•Specialization of Care (71)

•Logistical Approaches (73)

•Culture of Safety (88)

•Technologic Approaches (211)

•Education and Training (154)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (892)

•Health Care Executives and Administrators (990)

•Non-Health Care Professionals (351)

•Patients (31)

Setting of Care

•Hospitals (826)

•Psychiatric Facilities (7)

•Residential Facilities (27)

•Ambulatory Care (133)

•Outpatient Surgery (17)

•Patient Transport (16)

1 - 20 of 1143

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STUDY

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.

STUDY

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

STUDY

Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center.

McCullough J, McKenna D, Kadidlo D, et al. Blood. 2009:114:1684-1688.

STUDY

Specimen labeling errors in surgical pathology: an 18-month experience.

Layfield LJ, Anderson GM. Am J Clin Pathol. 2010;134:466-470.

STUDY

Mislabeling of cases, specimens, blocks, and slides: a College of American Pathologists study of 136 institutions.

Nakhleh RE, Idowu MO, Souers RJ, Meier FA, Bekeris LG. Arch Pathol Lab Med. 2011;135:969-974.

STUDY

Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention.

Tsai TT, Maddox TM, Roe MT, et al; National Cardiovascular Data Registry. JAMA. 2009;302:2458-2464.

COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

STUDY

Decreasing mislabeled laboratory specimens using barcode technology and bedside printers.

Brown JE, Smith N, Sherfy BR. J Nurs Care Qual. 2011;26:13-21.

STUDY

Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.

Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.

STUDY

Electronic health record-based surveillance of diagnostic errors in primary care.

Singh H, Giardina TD, Forjuoh SN, et al. BMJ Qual Saf. 2012;22:93-100.

MULTI-USE WEBSITE

Medical error.

Wikipedia.

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.

STUDY

Impact of a computerized physician order entry system on compliance with prescription accuracy requirements.

Mir C, Gadri A, Zelger GL, Pichon R, Pannatier A. Pharm World Sci. 2009;31:596-602.

STUDY

Unintentional therapeutic errors involving insulin in the ambulatory setting reported to poison centers.

Spiller HA, Borys DJ, Ryan ML, Sawyer TS, Wilson BL. Ann Pharmacother. 2011;45:17-22.

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 errors: the impact of prescribing and transcribing errors on preventable harm in hospitalised patients.

van Doormaal JE, van den Bemt PM, Mol PG, et al. Qual Saf Health Care. 2009;18:22-27.

STUDY

Computerized physician order entry of injectable antineoplastic drugs: an epidemiologic study of prescribing medication errors.

Nerich V, Limat S, Demarchi M, et al. Int J Med Inform. 2010;79:699-706.

STUDY

Accuracy of medication documentation in hospital discharge summaries: a retrospective analysis of medication transcription errors in manual and electronic discharge summaries.

Callen J, McIntosh J, Li J. Int J Med Inform. 2010;79:58-64.

STUDY

Prescription errors and outcomes related to inconsistent information transmitted through computerized order entry: a prospective study.

Singh H, Mani S, Espadas D, Petersen N, Franklin V, Petersen LA. Arch Intern Med. 2009;169:982-989.

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.

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