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 (62)

•Diagnostic Errors (114)

•Identification Errors (54)

•Discontinuities, Gaps, and Hand-Off Problems (141)

•Fatigue and Sleep Deprivation (17)

•Medication Safety (501)

•Medical Complications (181)

•Nonsurgical Procedural Complications (25)

•Surgical Complications (189)

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•Clinical Guideline (1)

•Journal Article (1118)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (258)

•Legal and Policy Approaches (53)

•Error Reporting and Analysis (488)

•Communication Improvement (199)

•Human Factors Engineering (126)

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•Technologic Approaches (225)

•Education and Training (167)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (927)

•Health Care Executives and Administrators (1030)

•Non-Health Care Professionals (368)

•Patients (36)

Setting of Care

•Hospitals (886)

•Psychiatric Facilities (6)

•Residential Facilities (27)

•Ambulatory Care (141)

•Outpatient Surgery (14)

•Patient Transport (16)

1 - 20 of 1212

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STUDY

Reducing inappropriate diagnostic practice through education and decision support.

Bairstow PJ, Persaud J, Mendelson R, Nguyen L. Int J Qual Health Care. 2010;22:194-200.

STUDY

Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review.

Santamaria J, Tobin A, Holmes J. Crit Care Med. 2010;38:445-450.

STUDY

Attitudes and barriers to a medical emergency team system at a tertiary paediatric hospital.

Azzopardi P, Kinney S, Moulden A, Tibballs J. Resuscitation. 2011;82:167-174.

STUDY

Accuracy of medication documentation in hospital discharge summaries: a retrospective analysis of medication transcription errors in manual and electronic discharge summaries.

Callen J, McIntosh J, Li J. Int J Med Inform. 2010;79:58-64.

STUDY

A trigger tool fails to identify serious errors and adverse events in pediatric otolaryngology.

Lander L, Roberson DW, Plummer KM, Forbes PW, Healy GB, Shah RK. Otolaryngol Head Neck Surg. 2010;143:480-486.

STUDY

Communication errors in dispatch of air medical transport.

Vilensky D, Macdonald RD. Prehosp Emerg Care. 2011;15:39-43.

STUDY

Patient record review of the incidence, consequences, and causes of diagnostic adverse events.

Zwaan L, de Bruijne M, Wagner C, et al. Arch Intern Med. 2010;170:1015-1021.

STUDY

Inability of providers to predict unplanned readmissions.

Allaudeen N, Schnipper JL, Orav EJ, Wachter RM, Vidyarthi AR. J Gen Intern Med. 2011;26:771-776.

STUDY

Using Medical Emergency Teams to detect preventable adverse events.

Iyengar A, Baxter A, Forster AJ. Crit Care. 2009;13:R126.

STUDY

Impact of a comprehensive safety initiative on patient-controlled analgesia errors.

Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.

STUDY

Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation.

Merry AF, Webster CS, Hannam J, et al. BMJ. 2011;343:d5543.

STUDY

An in-depth analysis of medication errors in hospitalized patients with HIV.

Snyder AM, Klinker K, Orrick JJ, Janelle J, Winterstein AG. Ann Pharmacother. 2011;45:459-468.

STUDY

Hospital costs associated with adverse events in gynecological oncology.

Kondalsamy-Chennakesavan S, Gordon LG, Sanday K, et al. Gynecol Oncol. 2011;121:70-75.

STUDY

Electronic health record-based surveillance of diagnostic errors in primary care.

Singh H, Giardina TD, Forjuoh SN, et al. BMJ Qual Saf. 2012;22:93-100.

STUDY

Critical incidents related to cardiac arrests reported to the Danish Patient Safety Database.

Andersen PO, Maaløe R, Andersen HB. Resuscitation. 2010;81:312-316.

STUDY

Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system.

Mattison MLP, Afonso KA, Ngo LH, Mukamal KJ. Arch Intern Med. 2010;170:1331-1336.

STUDY

Wrong-site sinus surgery in otolaryngology.

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

STUDY

ED overcrowding is associated with an increased frequency of medication errors.

Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. Am J Emerg Med. 2010;28:304-309.

STUDY

Reducing potentially fatal errors associated with high doses of insulin: a successful multifaceted multidisciplinary prevention strategy.

Dooley MJ, Wiseman M, McRae A, et al. BMJ Qual Saf. 2011;20:637-644.

STUDY

Medical errors and consequent adverse events in critically ill surgical patients in a tertiary care teaching hospital in Delhi.

Kumar S, Chaudhary S. J Emerg Trauma Shock. 2009;2:80-84.

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