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 (51)

•Diagnostic Errors (99)

•Identification Errors (50)

•Discontinuities, Gaps, and Hand-Off Problems (127)

•Fatigue and Sleep Deprivation (15)

•Medication Safety (549)

•Medical Complications (140)

•Nonsurgical Procedural Complications (18)

•Surgical Complications (209)

•Transfusion Complications (11)

•Psychological and Social Complications (23)

Origin/Sponsor

•Africa (3)

•Asia (34)

•Australia and New Zealand (45)

•Central and South America (7)

Resource Types

•Journal Article (1065)

•Meeting/Conference (1)

•Newspaper/Magazine Article (36)

•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 (220)

•Legal and Policy Approaches (41)

•Error Reporting and Analysis (473)

•Communication Improvement (186)

•Human Factors Engineering (113)

•Teamwork (42)

•Specialization of Care (78)

•Logistical Approaches (69)

•Culture of Safety (70)

•Technologic Approaches (253)

•Education and Training (145)

Clinical Areas

•Allied Health Services (1)

Target Audience

•Health Care Providers (805)

•Health Care Executives and Administrators (967)

•Non-Health Care Professionals (362)

•Patients (26)

Setting of Care

•Hospitals (829)

•Psychiatric Facilities (5)

•Residential Facilities (28)

•Ambulatory Care (140)

•Outpatient Surgery (15)

•Patient Transport (11)

1 - 20 of 1143

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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

How best to measure surgical quality? Comparison of the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution.

Cima RR, Lackore KA, Nehring SA, et al. Surgery. 2011;150:943-949.

STUDY

Improving documentation of a beta-blocker quality measure through an anesthesia information management system and real-time notification of documentation errors.

Nair BG, Peterson GN, Newman S, Wu W, Kolios-Morris V, Schwid HA. Jt Comm J Qual Patient Saf. 2012:38;283-288.

STUDY

The impact of electronic medical records data sources on an adverse drug event quality measure.

Kahn MG, Ranade D. J Am Med Inform Assoc. 2010;17:185-191.

STUDY

Electronic health records and adverse drug events after patient transfer.

Boockvar KS, Livote EE, Goldstein N, Nebeker JR, Siu A, Fried T. Qual Saf Health Care. 2010;19:e16.

STUDY

Medication errors with electronic prescribing (eP): two views of the same picture.

Savage I, Cornford T, Klecun E, Barber N, Clifford S, Franklin BD. BMC Health Serv Res. 2010;10:135.

STUDY

Exploring situational awareness in diagnostic errors in primary care.

Singh H, Davis Giardina T, Petersen LA, et al. BMJ Qual Saf. 2012;21:30-38.

STUDY

Critical drug–drug interactions for use in electronic health records systems with computerized physician order entry: review of leading approaches.

Classen DC, Phansalkar S, Bates DW. J Patient Saf. 2011;7:61-65.

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

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

Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review.

Hunt DL, Haynes RB, Hanna SE, Smith K. JAMA. 1998;280:1339-1346.

STUDY

The incidence and cost of unexpected hospital use after scheduled outpatient endoscopy.

Leffler DA, Kheraj R, Garud S, et al. Arch Intern Med. 2010;170:1752-1757.

STUDY

Evaluation of postoperative handover using a tool to assess information transfer and teamwork.

Nagpal K, Abboudi M, Fischler L, et al. Ann Surg. 2011;253:831-837.

STUDY

Adverse drug event rates in six community hospitals and the potential impact of computerized physician order entry for prevention.

Hug BL, Witkowski DJ, Sox CM, et al. J Gen Intern Med. 2010;25:31-38.

STUDY

An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies.

Palchuk MB, Fang EA, Cygielnik JM, et al. J Am Med Inform Assoc. 2010;17:472-476.

STUDY

Effect of computerized provider order entry with clinical decision support on adverse drug events in the long-term care setting.

Gurwitz JH, Field TS, Rochon P, et al. J Am Geriatr Soc. 2008;56:2225-2233.

STUDY

Impact of health information technology on detection of potential adverse drug events at the ordering stage.

Roberts LL, Ward MM, Brokel JM, Wakefield DS, Crandall DK, Conlon P. Am J Health Syst Pharm. 2010;67:1838-1846.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors occurring with the use of bar-code administration technology.

PA-PSRS Patient Saf Advis. December 2008;5:122-126.

STUDY

Postoperative sepsis in the United States.

Vogel TR, Dombrovskiy VY, Carson JL, Graham AM, Lowry SF. Ann Surg. 2010;252:1065-1071.

REVIEW

Year in review: medication mishaps in the elderly.

Peron EP, Marcum ZA, Boyce R, Hanlon JT, Handler SM. Am J Geriatr Pharmacother. 2011;9:1-10.

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