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 (71)

•Diagnostic Errors (123)

•Identification Errors (58)

•Discontinuities, Gaps, and Hand-Off Problems (175)

•Fatigue and Sleep Deprivation (28)

•Medication Safety (621)

•Medical Complications (197)

•Nonsurgical Procedural Complications (25)

•Surgical Complications (221)

•Transfusion Complications (14)

•Psychological and Social Complications (34)

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•Africa (4)

•Asia (39)

•Australia and New Zealand (59)

•Central and South America (7)

•Europe (276)

•North America (1097)

Resource Types

•Audiovisual (4)

•Book/Report (42)

•Clinical Guideline (1)

•Journal Article (1362)

•Legislation/Regulation (5)

•Meeting/Conference (2)

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•Newspaper/Magazine Article (52)

•Press Release/Announcement (3)

•Special or Theme Issue (3)

•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 (280)

•Legal and Policy Approaches (72)

•Error Reporting and Analysis (618)

•Communication Improvement (245)

•Human Factors Engineering (140)

•Teamwork (50)

•Specialization of Care (97)

•Logistical Approaches (107)

•Culture of Safety (100)

•Technologic Approaches (273)

•Education and Training (187)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (1072)

•Health Care Executives and Administrators (1196)

•Non-Health Care Professionals (430)

•Patients (58)

Setting of Care

•Hospitals (1062)

•Psychiatric Facilities (7)

•Residential Facilities (38)

•Ambulatory Care (178)

•Outpatient Surgery (23)

•Patient Transport (17)

1 - 20 of 1488

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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

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.

REVIEW

Avoiding wrong site surgery: a systematic review.

DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.

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.

REVIEW

Patient safety in dermatology: a review of the literature.

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

STUDY

Operating room briefings and wrong-site surgery.

Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.

STUDY

Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?

Seiden SC, Barach P. Arch Surg. 2006;141:931-939.

STUDY

Process changes to increase compliance with the Universal Protocol for bedside procedures.

Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.

STUDY

Medical errors in orthopaedics. Results of an AAOS member survey.

Wong DA, Herndon JH, Canale ST, et al. J Bone Joint Surg Am. 2009;91:547-557.

STUDY

Eight-year experience with a neurosurgical checklist.

Lyons MK. Am J Med Qual. 2010;25:285-288.

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

Toward understanding errors in inpatient psychiatry: a qualitative inquiry.

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

STUDY

Wrong-site sinus surgery in otolaryngology.

Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.

STUDY

Outcome of 6 years of protocol use for preventing wrong site office surgery.

Starling J 3rd, Coldiron BM. J Am Acad Dermatol. 2011;65:807-810.

STUDY

Paid malpractice claims for adverse events in inpatient and outpatient settings.

Bishop TF, Ryan AK, Casalino LP. JAMA. 2011;305:2427-2431.

REVIEW

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.

BOOK/REPORT

Adverse Health Events in Minnesota: Ninth Annual Public Report.

St. Paul, MN: Minnesota Department of Health; January 2013.

STUDY

Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers.

Kachalia A, Gandhi TK, Puopolo AL, et al. Ann Emerg Med. Ann Emerg Med. 2007;49:196-205.

COMMENTARY

Mistaken Identity

Hall LW. AHRQ WebM&M [serial online]. October 2008.

STUDY

An inpatient fall prevention initiative in a tertiary care hospital.

Weinberg J, Proske D, Szerszen A, et al. Jt Comm J Qual Patient Saf. 2011;37:317-325.

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