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 (96)

•Identification Errors (51)

•Discontinuities, Gaps, and Hand-Off Problems (162)

•Fatigue and Sleep Deprivation (27)

•Medication Safety (536)

•Medical Complications (197)

•Nonsurgical Procedural Complications (19)

•Surgical Complications (212)

•Transfusion Complications (11)

•Psychological and Social Complications (37)

Origin/Sponsor

•Africa (2)

•Asia (28)

•Australia and New Zealand (48)

•Central and South America (3)

•Europe (198)

•North America (1075)

Resource Types

•Audiovisual (4)

•Book/Report (52)

•Clinical Guideline (1)

•Journal Article (1227)

•Legislation/Regulation (5)

•Meeting/Conference (2)

•Newspaper/Magazine Article (49)

•Press Release/Announcement (1)

•Special or Theme Issue (2)

•Tools/Toolkit (1)

•Web Resource (12)

Error Types
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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (234)

•Legal and Policy Approaches (73)

•Error Reporting and Analysis (578)

•Communication Improvement (222)

•Human Factors Engineering (120)

•Teamwork (42)

•Specialization of Care (87)

•Logistical Approaches (98)

•Culture of Safety (92)

•Technologic Approaches (233)

•Education and Training (158)

Clinical Areas

•Allied Health Services (2)

•Medicine (1093)

•Nursing (108)

•Pharmacy (209)

Target Audience

•Health Care Providers (935)

•Health Care Executives and Administrators (1043)

•Non-Health Care Professionals (394)

•Patients (64)

Setting of Care

•Hospitals (1020)

•Psychiatric Facilities (6)

•Residential Facilities (32)

•Ambulatory Care (173)

•Outpatient Surgery (21)

•Patient Transport (13)

1 - 20 of 1356

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BOOK/REPORT

Patient Safety in Canada: An Update.

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

BOOK/REPORT

HealthGrades Sixth Annual Patient Safety in American Hospitals Study.

Golden, CO: HealthGrades, Inc.; April 2009.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.

Oakbrook Terrace, IL: The Joint Commission; January 2010.

NEWSPAPER/MAGAZINE ARTICLE

Never events: Utah hospitals saw nearly 60 serious errors in 2007.

May H. Salt Lake Tribune. August 18, 2008.

BOOK/REPORT

HealthGrades Quality Study: Fourth Annual Patient Safety in American Hospitals Study.

Golden, CO: HealthGrades, Inc.; April 2007.

BOOK/REPORT

HealthGrades Eighth Annual Patient Safety in American Hospitals Study.

Reed K, May R. Denver, CO: HealthGrades, Inc.; March 2011.

STUDY

Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the United States.

Bonis PA, Pickens GT, Rind DM, Foster DA. Int J Med Inform. 2008;77:745-753.

BOOK/REPORT

HealthGrades Quality Study: Fifth Annual Patient Safety in American Hospitals Study.

Golden, CO: HealthGrades, Inc.; April 2008.

STUDY

Impact of diagnosis-timing indicators on measures of safety, comorbidity, and case mix groupings from administrative data sources.

Naessens JM, Campbell CR, Berg B, Williams AR, Culbertson R. Med Care. 2007;45:781-788.

STUDY

Comparing measures of patient safety for inpatient care provided to veterans within and outside the VA system in New York.

Weeks WB, West AN, Rosen AK, Bagian JP. Qual Saf Health Care. 2008;17:58-64.

NEWSPAPER/MAGAZINE ARTICLE

New York City puts hospital error data online.

Kershaw S. New York Times. Sepember 7, 2007;Metro Desk section:B1.

STUDY

How do black-serving hospitals perform on patient safety indicators?: Implications for national public reporting and pay-for-performance.

Ly DP, Lopez L, Isaac T, Jha AK. Med Care. 2010;48:1133-1137.

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 2013.

STUDY

Examining the impact of the AHRQ Patient Safety Indicators (PSIs) on the Veterans Health Administration: the case of readmissions.

Rosen AK, Loveland S, Shin M, et al. Med Care. 2013;51:37-44.

DATABASE/DIRECTORY

HospitalInspections.org

Columbia, MO: Association of Health Care Journalists.

NEWSPAPER/MAGAZINE ARTICLE

Leapfrog hospital safety scores 'depressing.'

Clark C. HealthLeaders Media. May 9, 2013.

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.

BOOK/REPORT

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

Geneva, Switzerland: World Health Organization; 2011.

STUDY

The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries.

Press MJ, Silber JH, Rosen AK, et al. J Gen Intern Med. 2011;26:405-411.

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