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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•Device-related Complications (72)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (274)

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Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (1050)

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Setting of Care

•Hospitals (1050)

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•Outpatient Surgery (21)

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1 - 20 of 1463

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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

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.

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.

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.

STUDY

Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after 1,946,831 operations in children.

Camp M, Chang DC, Zhang Y, Chrouser K, Colombani PM, Abdullah F. Arch Surg. 2010;145:1085-1090.

REVIEW

Improving safety in the operating room: a systematic literature review of retained surgical sponges.

Wan W, Le T, Riskin L, Macario A. Curr Opin Anaesthesiol. 2009;22:207-214.

STUDY

Wrong-site sinus surgery in otolaryngology.

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

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

Surgical never events in the United States.

Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgery. 2013;153:465-472.

STUDY

Eight-year experience with a neurosurgical checklist.

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

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

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

Priority patient safety issues identified by perioperative nurses.

Steelman VM, Graling PR, Perkhounkova Y. AORN J. 2013;97:402-418.

REVIEW

The recurring problem of retained swabs and instruments.

Mahran MA, Toeima E, Morris EP. Best Pract Res Clin Obstet Gynaecol. 2013 Apr 8; [Epub ahead of print].

NEWSPAPER/MAGAZINE ARTICLE

Preventing wrong-site surgery in Minnesota: a 5-year journey.

Rydrych D, Apold J, Harder K. Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34.

STUDY

Using a data-matrix–coded sponge counting system across a surgical practice: impact after 18 months.

Cima RR, Kollengode A, Clark J, et al. Jt Comm J Qual Patient Saf. 2011;37:51-58.

STUDY

Operating room briefings and wrong-site surgery.

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

NEWSPAPER/MAGAZINE ARTICLE

Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.

Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.

STUDY

Incidence and characteristics of potential and actual retained foreign object events in surgical patients.

Cima RR, Kollengode A, Garnatz J, et al. J Am Coll Surg. 2008;207:80-87.

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