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 (81)

•Identification Errors (41)

•Discontinuities, Gaps, and Hand-Off Problems (132)

•Fatigue and Sleep Deprivation (17)

•Medication Safety (481)

•Medical Complications (186)

•Nonsurgical Procedural Complications (21)

•Surgical Complications (162)

•Transfusion Complications (10)

•Psychological and Social Complications (30)

Origin/Sponsor

•Africa (4)

•Asia (31)

•Australia and New Zealand (60)

•Central and South America (5)

Resource Types

•Clinical Guideline (1)

•Journal Article (1092)

•Legislation/Regulation (4)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (33)

•Press Release/Announcement (2)

•Special or Theme Issue (3)

•Tools/Toolkit (1)

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Error Types
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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (250)

•Legal and Policy Approaches (64)

•Error Reporting and Analysis (483)

•Communication Improvement (225)

•Human Factors Engineering (109)

•Teamwork (44)

•Specialization of Care (82)

•Logistical Approaches (76)

•Culture of Safety (104)

•Technologic Approaches (210)

•Education and Training (155)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (891)

•Health Care Executives and Administrators (994)

•Non-Health Care Professionals (377)

•Patients (48)

Setting of Care

•Hospitals (898)

•Psychiatric Facilities (6)

•Residential Facilities (28)

•Ambulatory Care (154)

•Outpatient Surgery (18)

•Patient Transport (15)

1 - 20 of 1202

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STUDY

Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.

Jain R, Kralovic SM, Evans ME, et al. N Engl J Med. 2011;364:1419-1430.

STUDY

Variation in safety culture dimensions within and between US and Swiss Hospital units: an exploratory study.

Schwendimann R, Zimmermann N, Küng K, Ausserhofer D, Sexton B. BMJ Qual Saf. 2013;22:32-41.

STUDY

Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii.

Lin DM, Weeks K, Holzmueller CG, Pronovost PJ, Pham JC. Jt Comm J Qual Patient Saf. 2013;39:51-60.

STUDY

Attitude is everything?: The impact of workload, safety climate, and safety tools on medical errors: a study of intensive care units.

Steyrer J, Schiffinger M, Huber C, Valentin A, Strunk G. Health Care Manage Rev. 2012 Oct 18; [Epub ahead of print].

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

Errors and omissions in hospital prescriptions: a survey of prescription writing in a hospital.

Calligaris L, Panzera A, Arnoldo L, et al. BMC Clin Pharmacol. 2009;9:9.

STUDY

A multidisciplinary approach to reduce central line–associated bloodstream infections.

McMullan C, Propper G, Schuhmacher C, et al. Jt Comm J Qual Patient Saf. 2013;39:61-69.

BOOK/REPORT

IBEAS: A Pioneer Study on Patient Safety in Latin America: Towards Safer Hospital Care.

Geneva, Switzerland: World Health Organization; 2011.

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

Are opioid dependence and methadone maintenance treatment (MMT) documented in the medical record? A patient safety issue.

Walley AY, Farrar D, Cheng DM, Alford DP, Samet JH. J Gen Intern Med. 2009;24:1007-1011.

STUDY

Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients' safety: assessor-blind pilot comparison.

Cappuccio FP, Bakewell A, Taggart FM, et al; for the Warwick EWTD Working Group. QJM. 2009;102:271-82.

STUDY

The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality.

Oake N, Taljaard M, van Walraven C, Wilson K, Roth V, Forster AJ. Arch Intern Med. 2010;170:1804-1810.

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

Large-scale deployment of the Global Trigger Tool across a large hospital system: refinements for the characterisation of adverse events to support patient safety learning opportunities.

Good VS, Saldaña M, Gilder R, Nicewander D, Kennerly DA. BMJ Qual Saf. 2011;20:25-30.

BOOK/REPORT

Patient Safety in Canada: An Update.

Ottawa, ON, Canada: Canadian Institute for Health Information; August 14, 2007.

MULTI-USE WEBSITE

HAC Posting on Hospital Compare.

Centers for Medicare & Medicaid Services.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2012.

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

Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events.

Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Murillo J, et al. J Epidemiol Community Health. 2008;62:1022-1029.

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