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 (60)

•Diagnostic Errors (113)

•Identification Errors (54)

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

•Fatigue and Sleep Deprivation (27)

•Medication Safety (593)

•Medical Complications (187)

•Nonsurgical Procedural Complications (21)

•Surgical Complications (192)

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•Africa (3)

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Resource Types

•Audiovisual (4)

•Book/Report (52)

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•Special or Theme Issue (4)

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Error Types
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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (269)

•Legal and Policy Approaches (77)

•Error Reporting and Analysis (645)

•Communication Improvement (237)

•Human Factors Engineering (115)

•Teamwork (43)

•Specialization of Care (87)

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•Technologic Approaches (255)

•Education and Training (196)

Clinical Areas

•Allied Health Services (6)

•Medicine (1150)

•Nursing (110)

•Pharmacy (226)

Target Audience

•Health Care Providers (986)

•Health Care Executives and Administrators (1118)

•Non-Health Care Professionals (419)

•Patients (59)

Setting of Care

•Hospitals (1012)

•Psychiatric Facilities (6)

•Residential Facilities (40)

•Ambulatory Care (190)

•Outpatient Surgery (19)

•Patient Transport (16)

1 - 20 of 1430

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STUDY

The cost of serious fall-related injuries at three midwestern hospitals.

Wong CA, Recktenwald AJ, Jones ML, Waterman BM, Bollini ML, Dunagan WC. Jt Comm J Qual Patient Saf. 2011;37:81-87.

STUDY

Exploring the causes of adverse events in hospitals and potential prevention strategies.

Smits M, Zegers M, Groenewegen PP, et al. Qual Saf Health Care. 2010;19:e5.

STUDY

Consequences of inadequate sign-out for patient care.

Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Arch Intern Med. 2008;168:1755-1760.

STUDY

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.

STUDY

The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience.

Viccellio A, Santora C, Singer AJ, Thode HC Jr, Henry MC. Ann Emerg Med. 2009;54:511-513.

STUDY

'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured.

Classen DC, Resar R, Griffin F, et al. Health Aff (Millwood). 2011;30:581-589.

STUDY

Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia.

Bismark MM, Spittal MJ, Gurrin LC, Ward M, Studdert DM. BMJ Qual Saf. 2013 Apr 10; [Epub ahead of print].

REVIEW

Suicide in the medical setting.

Ballard ED, Pao M, Henderson D, et al. Jt Comm J Qual Patient Saf. 2008;34:474-481.

STUDY

Emergency hospitalizations for adverse drug events in older Americans.

Budnitz DS, Lovegrove MC, Shehab N, Richards CL. N Engl J Med. 2011;365:2002-2012.

STUDY

A safety culture transformation: its effects at a children's hospital.

Peterson TH, Teman SF, Connors RH. J Patient Saf. 2012;8:125-130.

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

Anticoagulation-associated adverse drug events.

Piazza G, Nguyen TN, Cios D, et al. Am J Med. 2011;124:1136-1142.

STUDY

National estimates of adverse events during nonpsychiatric hospitalizations for persons with schizophrenia.

Khaykin E, Ford DE, Pronovost PJ, Dixon L, Daumit GL. Gen Hosp Psychiatry. 2010;32:419-425.

STUDY

Economic measurement of medical errors using a hospital claims database.

David G, Gunnarsson CL, Waters HC, Horblyuk R, Kaplan HS. Value Health. 2013;16:305-310.

STUDY

Smartphone use during inpatient attending rounds: prevalence, patterns and potential for distraction.

Katz-Sidlow RJ, Ludwig A, Miller S, Sidlow R. J Hosp Med. 2012;7:595-599.

STUDY

Implementing peer evaluation of handoffs: associations with experience and workload.

Arora VM, Greenstein EA, Woodruff JN, Staisiunas PG, Farnan JM. J Hosp Med. 2013;8:132-136.

STUDY

Contemporary evidence about hospital strategies for reducing 30-day readmissions: a national study.

Bradley EH, Curry L, Horwitz LI, et al. J Am Coll Cardiol. 2012;60:607-614.

STUDY

Using prospective clinical surveillance to identify adverse events in hospital.

Forster AJ, Worthington JR, Hawken S, et al. BMJ Qual Saf. 2011;20:756-763.

STUDY

Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.

Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.

STUDY

Assessment of adverse drug events among patients in a tertiary care medical center.

Johnston PE, France DJ, Byrne DW, et al. Am J Health Syst Pharm. 2006;63:2218-2227.

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