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 (53)

•Diagnostic Errors (73)

•Identification Errors (49)

•Discontinuities, Gaps, and Hand-Off Problems (115)

•Fatigue and Sleep Deprivation (19)

•Medication Safety (391)

•Medical Complications (140)

•Nonsurgical Procedural Complications (21)

•Surgical Complications (227)

•Transfusion Complications (11)

•Psychological and Social Complications (25)

Origin/Sponsor

•Africa (2)

•Asia (29)

•Australia and New Zealand (44)

•Central and South America (6)

•Europe (212)

•North America (676)

Resource Types

•Book/Report (22)

•Journal Article (916)

•Meeting/Conference (1)

•Newspaper/Magazine Article (31)

•Press Release/Announcement (2)

•Special or Theme Issue (2)

•Web Resource (3)

Error Types
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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (197)

•Legal and Policy Approaches (34)

•Error Reporting and Analysis (389)

•Communication Improvement (186)

•Human Factors Engineering (107)

•Teamwork (50)

•Specialization of Care (64)

•Logistical Approaches (69)

•Culture of Safety (72)

•Technologic Approaches (169)

•Education and Training (160)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (691)

•Health Care Executives and Administrators (869)

•Non-Health Care Professionals (324)

•Patients (18)

Setting of Care

•Hospitals (754)

•Psychiatric Facilities (3)

•Residential Facilities (17)

•Ambulatory Care (89)

•Outpatient Surgery (17)

•Patient Transport (12)

1 - 20 of 977

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STUDY

Communication failure in the operating room.

Halverson AL, Casey JT, Andersson J, et al. Surgery. 2011;49:305-310.

STUDY

A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative.

Arriaga AF, Elbardissi AW, Regenbogen SE, et al. Ann Surg. 2011;253:849-854.

STUDY

Evaluation of a preoperative team briefing: a new communication routine results in improved clinical practice.

Lingard L, Regehr G, Cartmill C, et al. BMJ Qual Saf. 2011;20:475-482.

STUDY

Interruptions and miscommunications in surgery: an observational study.

Gillespie BM, Chaboyer W, Fairweather N. AORN J. 2012;95:576-590.

STUDY

Assessing the impact of teaching patient safety principles to medical students during surgical clerkships.

Stahl K, Augenstein J, Schulman CI, Wilson K, McKenney M, Livingstone A. J Surg Res. 2011;170:e29-e40.

STUDY

The introduction of a surgical safety checklist in a tertiary referral obstetric centre.

Kearns RJ, Uppal V, Bonner J, Robertson J, Daniel M, McGrady EM. BMJ Qual Saf. 2011;20:818-822.

STUDY

The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre.

Mishra A, Catchpole K, McCulloch P. Qual Saf Health Care. 2009;18:104-108.

STUDY

Implementation of resident work hour restrictions is associated with a reduction in mortality and provider-related complications on the surgical service: a concurrent analysis of 14,610 patients.

Privette AR, Shackford SR, Osler T, Ratliff J, Sartorelli K, Hebert JC. Ann Surg. 2009;250:316-321.

STUDY

Surgeon's vigilance in the operating room.

Zheng B, Tien G, Atkins SM, et al. Am J Surg. 2011;201:667-671.

STUDY

Prevention of surgical malpractice claims by a surgical safety checklist.

de Vries EN, Eikens-Jansen MP, Hamersma AM, Smorenburg SM, Gouma DJ, Boermeester MA. Ann Surg. 2011;253:624-628.

STUDY

Use of the WHO surgical safety checklist in trauma and orthopaedic patients.

Sewell M, Adebibe M, Jayakumar P, et al. Int Orthop. 2011;35:897-901.

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

An evaluation of information transfer through the continuum of surgical care: a feasibility study.

Nagpal K, Vats A, Ahmed K, Vincent C, Moorthy K. Ann Surg. 2010;252:402-407.

STUDY

Poor resident–attending intraoperative communication may compromise patient safety.

Belyansky I, Martin TR, Prabhu AS, et al. J Surg Res. 2011;171:386-394.

STUDY

Thirty-day outcomes support implementation of a surgical safety checklist.

Bliss LA, Ross-Richardson CB, Sanzari LJ, et al. J Am Coll Surg. 2012;215:766-776.

COMMENTARY

The lost sponge: patient safety in the operating room.

Grant-Orser A, Davies P, Singh SS. CMAJ. 2012;184:1275-1278.

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.

REVIEW

Minimizing surgical error by incorporating objective assessment into surgical education.

Champion HR, Meglan DA, Shair EK. J Am Coll Surg. 2008;207:284-291.

STUDY

Classification of adverse events occurring in a surgical intensive care unit.

Frankel H, Sperry J, Kaplan L, Foley A, Rabinovici R. Am J Surg. 2007;194:328-332.

STUDY

Representative case series from public hospital admissions 1998 II: surgical adverse events.

Briant R, Morton J, Lay-Yee R, Davis P, Ali W. N Z Med J. 2005;118:U1591.

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