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 (52)

•Diagnostic Errors (78)

•Identification Errors (42)

•Discontinuities, Gaps, and Hand-Off Problems (178)

•Fatigue and Sleep Deprivation (19)

•Medication Safety (463)

•Medical Complications (144)

•Nonsurgical Procedural Complications (20)

•Surgical Complications (149)

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•Psychological and Social Complications (23)

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•Africa (4)

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Resource Types

•Book/Report (29)

•Clinical Guideline (1)

•Journal Article (971)

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•Newspaper/Magazine Article (21)

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•Special or Theme Issue (2)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (202)

•Legal and Policy Approaches (30)

•Error Reporting and Analysis (411)

•Communication Improvement (184)

•Human Factors Engineering (96)

•Teamwork (37)

•Specialization of Care (72)

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•Technologic Approaches (184)

•Education and Training (143)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (716)

•Health Care Executives and Administrators (923)

•Non-Health Care Professionals (318)

•Patients (13)

Setting of Care

•Hospitals (760)

•Psychiatric Facilities (3)

•Residential Facilities (37)

•Ambulatory Care (114)

•Outpatient Surgery (10)

•Patient Transport (11)

1 - 20 of 1032

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STUDY

Development of a core drug list towards improving prescribing education and reducing errors in the UK.

Baker E, Roberts AP, Wilde K, et al. Br J Clin Pharmacol. 2011;71:190-198.

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

Transfers of patient care between house staff on internal medicine wards: a national survey.

Horwitz LI, Krumholz HM, Green ML, Huot SJ. Arch Intern Med. 2006;166:1173-1177.

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

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.

STUDY

Pharmacists' interventions in prescribing errors at hospital discharge: an observational study in the context of an electronic prescribing system in a UK teaching hospital.

Abdel-Qader DH, Harper L, Cantrill JA, Tully MP. Drug Saf. 2010;33:1027-1044.

REVIEW

Addressing postdischarge adverse events: a neglected area.

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

STUDY

Medication reconciliation performed by pharmacy technicians at the time of preoperative screening.

van den Bemt PM, van den Broek S, van Nunen AK, Harbers JB, Lenderink AW. Ann Pharmacother. 2009;43:868-874.

STUDY

Interruptions and multitasking in nursing care.

Kalisch BJ, Aebersold M. Jt Comm J Qual Patient Saf. 2010;36:126-132.

STUDY

Error rates in breast imaging reports: comparison of automatic speech recognition and dictation transcription.

Basma S, Lord B, Jacks LM, Rizk M, Scaranelo AM. AJR Am J Roentgenol. 2011;197:923-927.

STUDY

The introduction of a surgical safety checklist in a tertiary referral obstetric centre.

Kearns RJ, Uppal V, Bonner J, Robertson J, Daniel M, McGrady EM. BMJ Qual Saf. 2011;20:818-822.

STUDY

The social dimensions of safety incident reporting in maternity care: the influence of working relationships and group processes.

Lindsay P, Sandall J, Humphrey C. Soc Sci Med. 2012;75:1793-1799.

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

Contributing factors identified by hospital incident report narratives.

Nuckols TK, Bell DS, Paddock SM, Hilborne LH. Qual Saf Health Care. 2008;17:368-372.

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

Fall prevention in acute care hospitals: a randomized trial.

Dykes PC, Carroll DL, Hurley A, et al. JAMA. 2010;304:1912-1918.

STUDY

Adverse events detected by clinical surveillance on an obstetric service.

Forster AJ, Fung I, Caughey S, et al. Obstet Gynecol. 2006;108:1073-1083.

STUDY

Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place.

Olsen S, Neale G, Schwab K, et al. Qual Saf Health Care. 2007;16:40-44.

STUDY

Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System.

Hutchinson A, Young TA, Cooper KL, et al. Qual Saf Health Care. 2009;18:5-10.

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