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 (73)

•Diagnostic Errors (121)

•Identification Errors (55)

•Discontinuities, Gaps, and Hand-Off Problems (182)

•Fatigue and Sleep Deprivation (27)

•Medication Safety (626)

•Medical Complications (205)

•Nonsurgical Procedural Complications (23)

•Surgical Complications (216)

•Transfusion Complications (12)

•Psychological and Social Complications (34)

Origin/Sponsor

•Africa (3)

•Asia (39)

•Australia and New Zealand (61)

•Central and South America (7)

•Europe (282)

•North America (1103)

Resource Types

•Audiovisual (4)

•Book/Report (44)

•Clinical Guideline (1)

•Journal Article (1378)

•Legislation/Regulation (3)

•Meeting/Conference (2)

•Newspaper/Magazine Article (52)

•Press Release/Announcement (2)

•Special or Theme Issue (2)

•Tools/Toolkit (1)

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Error Types
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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (274)

•Legal and Policy Approaches (75)

•Error Reporting and Analysis (627)

•Communication Improvement (244)

•Human Factors Engineering (129)

•Teamwork (45)

•Specialization of Care (95)

•Logistical Approaches (99)

•Culture of Safety (97)

•Technologic Approaches (271)

•Education and Training (176)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (1038)

•Health Care Executives and Administrators (1193)

•Non-Health Care Professionals (440)

•Patients (57)

Setting of Care

•Hospitals (1075)

•Psychiatric Facilities (6)

•Residential Facilities (34)

•Ambulatory Care (196)

•Outpatient Surgery (20)

•Patient Transport (17)

1 - 20 of 1498

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STUDY

Identifying diagnostic errors in primary care using an electronic screening algorithm.

Singh H, Thomas EJ, Khan MM, Petersen LA. Arch Intern Med. 2007;167:302-308.

STUDY

Patient safety in out-of-hours primary care: a review of patient records.

Smits M, Huibers L, Kerssemeijer B, de Feijter E, Wensing M, Giesen P. BMC Health Serv Res. 2010;10:335.

STUDY

Patient safety perceptions of primary care providers after implementation of an electronic medical record system.

McGuire MJ, Noronha G, Samal L, Yeh HC, Crocetti S, Kravet S. J Gen Intern Med. 2013;28:184-192.

STUDY

Types and origins of diagnostic errors in primary care settings.

Singh H, Giardina TD, Meyer AND, Forjuoh SN, Reis MD, Thomas EJ. JAMA Intern Med. 2013;173:418-425.

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.

STUDY

In-home medication reviews: a novel approach to improving patient care through coordination of care.

Willis JS, Hoy RH, Jenkins WD. J Community Health. 2011;36:1027-1031.

STUDY

Diagnostic errors in primary care: lessons learned.

Ely JW, Kaldjian LC, D'Alessandro DM. J Am Board Fam Med. 2012;25:87-97.

STUDY

Electronic medical record availability and primary care depression treatment.

Harman JS, Rost KM, Harle CA, Cook RL. J Gen Intern Med. 2012;27:962-967.

STUDY

Adverse drug events in general practice patients in Australia.

Miller GC, Britt HC, Valenti L. Med J Aust. 2006;184:321-324.

STUDY

Pharmacist-supported medication review training for general practitioners: feasibility and acceptability.

Krska J, Gill D, Hansford D. Med Educ. 2006;40:1217-1225.

STUDY

Direct reporting of laboratory test results to patients by mail to enhance patient safety.

Sung S, Forman-Hoffman V, Wilson MC, Cram P. J Gen Intern Med. 2006;21:1075-78.

STUDY

Missed opportunities in the primary care management of early acute ischemic heart disease.

Sequist TD, Marshall R, Lampert S, Buechler EJ, Lee TH. Arch Intern Med. 2006;166:2237-2243.

STUDY

Residents' perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements.

Ratanawongsa N, Bolen S, Howell EE, Kern DE, Sisson SD, Larriviere D. J Gen Intern Med. 2006;21:758-763.

STUDY

Problems after discharge and understanding of communication with their primary care physicians (PCPs) among hospitalized seniors: a mixed methods study.

Arora VM, Prochaska ML, Farnan JM, et al. J Hosp Med. 2010;5:385-391.

STUDY

Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients.

Brenner S, Detz A, López A, Horton C, Sarkar U. BMJ Qual Saf. 2012;21:670-675.

STUDY

A steep increase in domestic fatal medication errors with use of alcohol and/or street drugs.

Phillips DP, Barker GEC, Eguchi MM. Arch Intern Med. 2008;168:1561-1566.

AUDIOVISUAL PRESENTATION

Medication error death rate up 500 percent.

Spiesel S, Chadwick A. "Day to Day." National Public Radio. August 27, 2008.

STUDY

Sources and types of discrepancies between electronic medical records and actual outpatient medication use.

Orrico KB. J Manag Care Pharm. 2008;14:626-631.

COMMENTARY

Eliminating preventable death at Ascension Health.

Tolchin S, Brush R, Lange P, Bates P, Garbo JJ. Jt Comm J Qual Patient Saf. 2007;33:145-154.

STUDY

Patient report on information given, consultation time and safety in primary care.

Mira JJ, Nebot C, Lorenzo S, Pérez-Jover V. Qual Saf Health Care. 2010;19:e33.

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