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 (75)

•Identification Errors (40)

•Discontinuities, Gaps, and Hand-Off Problems (147)

•Fatigue and Sleep Deprivation (25)

•Medication Safety (541)

•Medical Complications (136)

•Nonsurgical Procedural Complications (12)

•Surgical Complications (142)

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•Africa (2)

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Resource Types

•Audiovisual (4)

•Book/Report (29)

•Journal Article (1012)

•Legislation/Regulation (3)

•Meeting/Conference (2)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (188)

•Legal and Policy Approaches (58)

•Error Reporting and Analysis (451)

•Communication Improvement (200)

•Human Factors Engineering (97)

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•Technologic Approaches (221)

•Education and Training (126)

Clinical Areas

•Allied Health Services (4)

•Medicine (881)

•Nursing (93)

•Pharmacy (206)

Target Audience

•Health Care Providers (780)

•Health Care Executives and Administrators (835)

•Non-Health Care Professionals (306)

•Patients (49)

Setting of Care

•Hospitals (769)

•Psychiatric Facilities (4)

•Residential Facilities (34)

•Ambulatory Care (154)

•Outpatient Surgery (16)

•Patient Transport (15)

1 - 20 of 1110

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STUDY

Enhancing patient safety with intelligent intravenous infusion devices: experience in a specialty cardiac hospital.

Wood JL, Burnette JS. Heart Lung. 2012;41:173-176.

STUDY

Medication errors resulting from computer entry by nonprescribers.

Santell JP, Kowiatek JG, Weber RJ, Hicks RW, Sirio CA. Am J Health Syst Pharm. 2009;66:843-853.

STUDY

Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes.

Lapane KL, Hughes CM, Daiello LA, Cameron KA, Feinberg J. J Am Geriatr Soc. 2011;59:1238-1245.

NEWSPAPER/MAGAZINE ARTICLE

Mistakes, some deadly, haunt county jails.

Carter M. Seattle Times. March 9, 2007:A1.

COMMENTARY

Smart pumps: advanced capabilities and continuous quality improvement.

Vanderveen T. Patient Saf Quality Healthc. January/February 2007.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

STUDY

Application of the IV Medication Harm Index to assess the nature of harm averted by "smart" infusion safety systems.

Williams CK, Maddox RR, Heape E, et al. J Patient Saf. 2006;2:132-139.

STUDY

Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial.

Schnipper JL, Hamann C, Ndumele CD, et al. Arch Intern Med. 2009;169:771-780.

PRESS RELEASE/ANNOUNCEMENT

2007 Study of Injectable Medication Errors.

Silver Spring, MD: American Nurses Association; June 18, 2007.

STUDY

Evaluation of causes and frequency of medication errors during information technology downtime.

Hanuscak TL, Szeinbach SL, Seoane-Vazquez E, Reichert BJ, McCluskey CF. Am J Health Syst Pharm. 2009;66:1119-1124.

STUDY

Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events.

Nuckols TK, Bower AG, Paddock SM, et al. J Gen Intern Med. 2008;23(suppl 1):41-45.

STUDY

Identifying discrepancies in electronic medical records through pharmacist medication reconciliation.

Stewart AL, Lynch KJ. J Am Pharm Assoc (2003). 2012;52:59-66.

STUDY

Reliability evaluation of the adapted National Coordinating Council Medication Error Reporting and Prevention (NCC MERP) index.

Snyder RA, Abarca J, Meza JL, Rothschild JM, Rizos A, Bates DW. Pharmacoepidemiol Drug Saf. 2007:16:1006-1013.

STUDY

Transitioning between electronic health records: effects on ambulatory prescribing safety.

Abramson EL, Malhotra S, Fischer K, et al. J Gen Intern Med. 2011;26:868-874.

COMMENTARY

Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge.

Murphy EM, Oxencis CJ, Klauck JA, Meyer DA, Zimmerman JM. Am J Health Syst Pharm. 2009;66:2126-2131.

STUDY

Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients.

Holdsworth MT, Fichtl RE, Raisch DW, et al. Pediatrics. 2007;120:1058-1066.

REVIEW

Epidemiology of medication-related adverse events in nursing homes.

Handler SM, Wright RM, Ruby CM, Hanlon JT. Am J Geriatr Pharmacother. 2006;4:264-272.

STUDY

Potentially inappropriate medications and adverse drug effects in elders in the ED.

Nixdorff N, Hustey FM, Brady AK, Vaji K, Leonard M, Messinger-Rapport BJ. Am J Emerg Med. 2008;26:697-700.

STUDY

Adverse events associated with procedural sedation and analgesia in a pediatric emergency department: a comparison of common parenteral drugs.

Roback MG, Wathen JE, Bajaj L, Bothner JP. Acad Emerg Med. 2005;12:508-513.

STUDY

Internal reporting system to improve a pharmacy's medication distribution process.

Rickrode GA, Williams-Lowe ME, Rippe JL, Theriault RH Jr. Am J Health Syst Pharm. 2007;64:1197-1202.

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