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 (73)

•Diagnostic Errors (120)

•Identification Errors (58)

•Discontinuities, Gaps, and Hand-Off Problems (176)

•Fatigue and Sleep Deprivation (28)

•Medication Safety (629)

•Medical Complications (198)

•Nonsurgical Procedural Complications (25)

•Surgical Complications (229)

•Transfusion Complications (14)

•Psychological and Social Complications (34)

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•Africa (4)

•Asia (38)

•Australia and New Zealand (62)

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Resource Types

•Audiovisual (4)

•Book/Report (43)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (280)

•Legal and Policy Approaches (71)

•Error Reporting and Analysis (623)

•Communication Improvement (245)

•Human Factors Engineering (147)

•Teamwork (50)

•Specialization of Care (97)

•Logistical Approaches (107)

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•Technologic Approaches (274)

•Education and Training (190)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (1077)

•Health Care Executives and Administrators (1205)

•Non-Health Care Professionals (434)

•Patients (58)

Setting of Care

•Hospitals (1079)

•Psychiatric Facilities (6)

•Residential Facilities (38)

•Ambulatory Care (177)

•Outpatient Surgery (22)

•Patient Transport (18)

1 - 20 of 1504

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REVIEW

Avoiding wrong site surgery: a systematic review.

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

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.

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.

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

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

Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.

Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.

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

Wrong-site sinus surgery in otolaryngology.

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

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

Eight-year experience with a neurosurgical checklist.

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

STUDY

Validity of selected patient safety indicators: opportunities and concerns.

Kaafarani HM, Borzecki AM, Itani KM, et al. J Am Coll Surg. 2011; 212:924-934.

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

Effect of a 19-item surgical safety checklist during urgent operations in a global patient population.

Weiser TG, Haynes AB, Dziekan G, et al; Safe Surgery Saves Lives Investigators and Study Group. Ann Surg. 2010;251:976-980.

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

Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center.

McCullough J, McKenna D, Kadidlo D, et al. Blood. 2009:114:1684-1688.

STUDY

Deconstructing intraoperative communication failures.

Hu YY, Arriaga AF, Peyre SE, Corso KA, Roth EM, Greenberg CC. J Surg Res. 2012;177:37-42.

STUDY

Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections.

Wick EC, Hobson DB, Bennett JL, et al. J Am Coll Surg. 2012;215;193-200.

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