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 (59)

•Diagnostic Errors (98)

•Identification Errors (53)

•Discontinuities, Gaps, and Hand-Off Problems (166)

•Fatigue and Sleep Deprivation (28)

•Medication Safety (564)

•Medical Complications (179)

•Nonsurgical Procedural Complications (19)

•Surgical Complications (178)

•Transfusion Complications (11)

•Psychological and Social Complications (35)

Origin/Sponsor

•Africa (2)

•Asia (31)

•Australia and New Zealand (44)

•Central and South America (6)

•Europe (205)

•North America (1082)

Resource Types

•Audiovisual (4)

•Book/Report (56)

•Clinical Guideline (1)

•Journal Article (1233)

•Legislation/Regulation (5)

•Meeting/Conference (2)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (49)

•Press Release/Announcement (1)

•Special or Theme Issue (3)

•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 (74)

•Error Reporting and Analysis (634)

•Communication Improvement (224)

•Human Factors Engineering (110)

•Teamwork (38)

•Specialization of Care (79)

•Logistical Approaches (97)

•Culture of Safety (92)

•Technologic Approaches (232)

•Education and Training (156)

Clinical Areas

•Allied Health Services (5)

•Medicine (1090)

•Nursing (111)

•Pharmacy (220)

Target Audience

•Health Care Providers (933)

•Health Care Executives and Administrators (1040)

•Non-Health Care Professionals (385)

•Patients (64)

Setting of Care

•Hospitals (994)

•Psychiatric Facilities (7)

•Residential Facilities (34)

•Ambulatory Care (184)

•Outpatient Surgery (20)

•Patient Transport (14)

1 - 20 of 1368

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STUDY

Analysis of Australian newspaper coverage of medication errors.

Hinchcliff R, Westbrook J, Greenfield D, Baysari M, Moldovan M, Braithwaite J. Int J Qual Health Care. 2012;24:1-8.

NEWSPAPER/MAGAZINE ARTICLE

Lessons from America's safest hospitals.

Howard B. AARP The Magazine. April/May 2013;56:46-50,52,71.

NEWSPAPER/MAGAZINE ARTICLE

Hospital safety: your responsibility or theirs?

Teegardin C. Atlanta Journal-Constitution. April 28, 2013.

NEWSPAPER/MAGAZINE ARTICLE

Far more could be done to stop the deadly bacteria C. diff.

Eisler P. USA Today. August 16, 2012.

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

Medicaid, hospital financial stress, and the incidence of adverse medical events for children.

Smith RB, Dynan L, Fairbrother G, Chabi G, Simpson L. Health Serv Res. 2012;47:1621-1641.

STUDY

Is it possible to identify risks for injurious falls in hospitalized patients?

Mion LC, Chandler AM, Waters TM, et al. Jt Comm J Qual Patient Saf. 2012;38:408-413.

STUDY

Supratherapeutic dosing of acetaminophen among hospitalized patients.

Zhou L, Maviglia SM, Mahoney LM, et al. Arch Intern Med. 2012;172:1721-1728.

NEWSPAPER/MAGAZINE ARTICLE

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

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

STUDY

Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States.

Aiken LH, Sermeus W, Van den Heede K, et al. BMJ. 2012;344:e1717.

REVIEW

Twenty-four/seven: a mixed-method systematic review of the off-shift literature.

de Cordova PB, Phibbs CS, Bartel AP, Stone PW. J Adv Nurs. 2012;68:1454-1468.

NEWSPAPER/MAGAZINE ARTICLE

New York City puts hospital error data online.

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

COMMENTARY

Smart pumps: advanced capabilities and continuous quality improvement.

Vanderveen T. Patient Saf Quality Healthc. January/February 2007.

STUDY

Medication reconciliation for reducing drug-discrepancy adverse events.

Boockvar KS, Carlson Lacorte H, Giambanco V, Fridman B, Siu A. Am J Geriatr Pharmacother. 2006;4:236-243.

STUDY

Drug shortage-associated increase in catheter-related blood stream infection in children.

Ralls MW, Blackwood RA, Arnold MA, Partipilo ML, Dimond J, Teitelbaum DH. Pediatrics. 2012;130:e1369-e1373.

NEWSPAPER/MAGAZINE ARTICLE

U.S. to delete data on life-threatening mistakes from website.

Babcock CR. Bloomberg News. May 1, 2013.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: when pharmacy is closed.

PA-PSRS Patient Saf Advis. March 2012;9:11-17.

STUDY

Impact of attending physician workload on patient care: a survey of hospitalists.

Michtalik HJ, Yeh H, Pronovost PJ, Brotman DJ. JAMA Intern Med. 2013;173:375-377.

STUDY

Using the patient safety indicators to detect potential safety events among US veterans with psychotic disorders: clinical and research implications.

Smith EG, Zhao S, Rosen AK. Int J Qual Health Care. 2012;24:321-329.

STUDY

Economic measurement of medical errors using a hospital claims database.

David G, Gunnarsson CL, Waters HC, Horblyuk R, Kaplan HS. Value Health. 2013;16:305-310.

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