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 (58)

•Diagnostic Errors (110)

•Identification Errors (47)

•Discontinuities, Gaps, and Hand-Off Problems (140)

•Fatigue and Sleep Deprivation (19)

•Medication Safety (483)

•Medical Complications (157)

•Nonsurgical Procedural Complications (24)

•Surgical Complications (178)

•Transfusion Complications (11)

•Psychological and Social Complications (24)

Origin/Sponsor

•Africa (4)

•Asia (33)

•Australia and New Zealand (56)

•Central and South America (8)

Resource Types

•Clinical Guideline (1)

•Journal Article (1067)

•Legislation/Regulation (4)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (22)

•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 (238)

•Legal and Policy Approaches (43)

•Error Reporting and Analysis (453)

•Communication Improvement (197)

•Human Factors Engineering (122)

•Teamwork (45)

•Specialization of Care (73)

•Logistical Approaches (74)

•Culture of Safety (86)

•Technologic Approaches (219)

•Education and Training (160)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (902)

•Health Care Executives and Administrators (986)

•Non-Health Care Professionals (351)

•Patients (28)

Setting of Care

•Hospitals (823)

•Psychiatric Facilities (7)

•Residential Facilities (27)

•Ambulatory Care (149)

•Outpatient Surgery (14)

•Patient Transport (15)

1 - 20 of 1146

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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.

STUDY

Exploring situational awareness in diagnostic errors in primary care.

Singh H, Davis Giardina T, Petersen LA, et al. BMJ Qual Saf. 2012;21:30-38.

COMMENTARY

Urine a Tough Position.

Gandhi TK. AHRQ WebM&M [serial online]. October 2003.

STUDY

Impact of implementing alerts about medication black-box warnings in electronic health records.

Yu DT, Seger DL, Lasser KE, et al. Pharmacoepidemiol Drug Saf. 2011;20:192-202.

REVIEW

Patient safety in dermatology: a review of the literature.

Cao LY, Taylor JS, Vidimos A. Dermatol Online J. 2010;16:3.

STUDY

Utility of clinical examination in the diagnosis of emergency department patients admitted to the department of medicine of an academic hospital.

Paley L, Zornitzki T, Cohen J, Friedman J, Kozak N, Schattner A. Arch Intern Med. 2011;171:1394-1396.

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

Medication errors with electronic prescribing (eP): two views of the same picture.

Savage I, Cornford T, Klecun E, Barber N, Clifford S, Franklin BD. BMC Health Serv Res. 2010;10:135.

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

The relationship of self-report of quality to practice size and health information technology.

Gorman PN, O'Malley JP, Fagnan LJ. J Am Board Fam Med. 2012;25:614-624.

STUDY

Relating faults in diagnostic reasoning with diagnostic errors and patient harm.

Zwaan L, Thijs A, Wagner C, van der Wal G, Timmermans DR. Acad Med. 2012;87:149-156.

REVIEW

Addressing postdischarge adverse events: a neglected area.

Tsilimingras D, Bates DW. Jt Comm J Qual Patient Saf. 2008;34:85-97.

STUDY

Electronic health records and adverse drug events after patient transfer.

Boockvar KS, Livote EE, Goldstein N, Nebeker JR, Siu A, Fried T. Qual Saf Health Care. 2010;19:e16.

STUDY

Effect of admission medication reconciliation on adverse drug events from admission medication changes.

Boockvar KS, Blum S, Kugler A, et al. Arch Intern Med. 2011;171:860-861.

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

Toward understanding errors in inpatient psychiatry: a qualitative inquiry.

Cullen SW, Nath SB, Marcus SC. Psychiatr Q. 2010;81:197-205.

STUDY

Automated identification of postoperative complications within an electronic medical record using natural language processing.

Murff HJ, FitzHenry F, Matheny ME, et al. JAMA. 2011;306:848-855.

STUDY

High performance teamwork training and systems redesign in outpatient oncology.

Bunnell CA, Gross AH, Weingart SN, et al. BMJ Qual Saf. 2013;22:405-413.

STUDY

Safety of using a computerized rounding and sign-out system to reduce resident duty hours.

Van Eaton EG, McDonough K, Lober WB, Johnson EA, Pellegrini CA, Horvath KD. Acad Med. 2010;85:1189-1195.

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