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 (66)

•Diagnostic Errors (110)

•Identification Errors (58)

•Discontinuities, Gaps, and Hand-Off Problems (172)

•Fatigue and Sleep Deprivation (26)

•Medication Safety (546)

•Medical Complications (184)

•Nonsurgical Procedural Complications (22)

•Surgical Complications (236)

•Transfusion Complications (13)

•Psychological and Social Complications (30)

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•Africa (4)

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Resource Types

•Audiovisual (4)

•Book/Report (39)

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•Journal Article (1235)

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•Press Release/Announcement (3)

•Special or Theme Issue (3)

•Tools/Toolkit (1)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (256)

•Legal and Policy Approaches (70)

•Error Reporting and Analysis (554)

•Communication Improvement (243)

•Human Factors Engineering (130)

•Teamwork (45)

•Specialization of Care (89)

•Logistical Approaches (101)

•Culture of Safety (89)

•Technologic Approaches (249)

•Education and Training (169)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (1029)

•Health Care Executives and Administrators (1063)

•Non-Health Care Professionals (377)

•Patients (61)

Setting of Care

•Hospitals (970)

•Psychiatric Facilities (5)

•Residential Facilities (39)

•Ambulatory Care (173)

•Outpatient Surgery (23)

•Patient Transport (18)

1 - 20 of 1358

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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

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

Implementing a surgical checklist: more than checking a box.

Levy SM, Senter CE, Hawkins RB, et al. Surgery. 2012;152:331-336.

COMMENTARY

Learning from adverse events and near misses.

Greenberg CC. J Gastrointest Surg. 2008;13:3-5.

STUDY

Interruptions and miscommunications in surgery: an observational study.

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

STUDY

Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study.

van Klei WA, Hoff RG, van Aarnhem EE, et al. Ann Surg. 2012;255:44-49.

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.

NEWSPAPER/MAGAZINE ARTICLE

Preventing wrong-site surgery in Minnesota: a 5-year journey.

Rydrych D, Apold J, Harder K. Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34.

REVIEW

Avoiding wrong site surgery: a systematic review.

DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.

COMMENTARY

Using medical malpractice closed claims data to reduce surgical risk and improve patient safety.

Manuel BM, Greenwald LM. Bull Am Coll Surg. March 2007;92:27-30.

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

Postoperative sepsis in the United States.

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

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.

STUDY

Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality.

Anderson CI, Nelson CS, Graham CF, et al. J Surg Res. 2012;177:43-48.

STUDY

Simulation-based trial of surgical-crisis checklists.

Arriaga AF, Bader AM, Wong JM, et al. N Engl J Med. 2013;368:246-253.

STUDY

Infection control assessment of ambulatory surgical centers.

Schaefer MK, Jhung M, Dahl M, et al. JAMA. 2010;303:2273-2279.

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

Safety culture and complications after bariatric surgery.

Birkmeyer NJ, Finks JF, Greenberg CK, et al. Ann Surg. 2013;257:260-265.

STUDY

Safe surgery: how accurate are we at predicting intra-operative blood loss?

Solon JG, Egan C, McNamara DA. J Eval Clin Pract. 2013;19:100-105.

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