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 (65)

•Diagnostic Errors (104)

•Identification Errors (54)

•Discontinuities, Gaps, and Hand-Off Problems (169)

•Fatigue and Sleep Deprivation (28)

•Medication Safety (612)

•Medical Complications (198)

•Nonsurgical Procedural Complications (22)

•Surgical Complications (191)

•Transfusion Complications (12)

•Psychological and Social Complications (39)

Origin/Sponsor

•Africa (3)

•Asia (35)

•Australia and New Zealand (52)

•Central and South America (7)

•Europe (281)

•North America (1085)

Resource Types

•Audiovisual (4)

•Book/Report (58)

•Clinical Guideline (1)

•Journal Article (1320)

•Legislation/Regulation (5)

•Meeting/Conference (2)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (52)

•Press Release/Announcement (2)

•Special or Theme Issue (4)

•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 (254)

•Legal and Policy Approaches (82)

•Error Reporting and Analysis (625)

•Communication Improvement (237)

•Human Factors Engineering (120)

•Teamwork (43)

•Specialization of Care (86)

•Logistical Approaches (105)

•Culture of Safety (108)

•Technologic Approaches (256)

•Education and Training (176)

Clinical Areas

•Allied Health Services (5)

•Medicine (1158)

•Nursing (125)

•Pharmacy (235)

Target Audience

•Health Care Providers (1007)

•Health Care Executives and Administrators (1127)

•Non-Health Care Professionals (423)

•Patients (64)

Setting of Care

•Hospitals (1052)

•Psychiatric Facilities (7)

•Residential Facilities (38)

•Ambulatory Care (187)

•Outpatient Surgery (20)

•Patient Transport (14)

1 - 20 of 1462

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STUDY

Exploring relationships between patient safety culture and patients' assessments of hospital care.

Sorra J, Khanna K, Dyer N, Mardon R, Famolaro T. J Patient Saf. 2012;8:131-139.

STUDY

Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods.

Payne CE, Stein JM, Leong T, Dressler DD. BMJ Qual Saf. 2012;21:925-932.

STUDY

Variations in surgical outcomes associated with hospital compliance with safety practices.

Brooke BS, Dominici F, Pronovost PJ, Makary MA, Schneider E, Pawlik TM. Surgery. 2012;151:651-659.

BOOK/REPORT

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

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

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

An organizational assessment of disruptive clinician behavior: findings and implications.

Walrath JM, Dang D, Nyberg D. J Nurs Care Qual. 2013;28:110-121.

STUDY

Patient reports of undesirable events during hospitalization.

Agoritsas T, Bovier PA, Perneger TV. J Gen Intern Med. 2005;20:922-928.

STUDY

What do patients think about year-end resident continuity clinic handoffs?: a qualitative study.

Pincavage AT, Lee WW, Beiting KJ, Arora VM. J Gen Intern Med. 2013 Apr 18; [Epub ahead of print].

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

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2012.

Oakbrook Terrace, IL: The Joint Commission; September 2012.

STUDY

Evaluation of a nurse-led safety program in a critical care unit.

Saladino L, Pickett LC, Frush K, Mall A, Champagne MT. J Nurs Care Qual. 2013;28:139-146.

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

Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis.

Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. BMJ. 2011;342:d219.

STUDY

Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients.

Cornu P, Steurbaut S, Leysen T, et al. Ann Pharmacother. 2012;46:484-494.

STUDY

Do nurse and patient injuries share common antecedents? An analysis of associations with safety climate and working conditions.

Taylor JA, Dominici F, Agnew J, Gerwin D, Morlock L, Miller MR. BMJ Qual Saf. 2012;21:101-111.

BOOK/REPORT

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

Geneva, Switzerland: World Health Organization; 2011.

BOOK/REPORT

Patient Safety in Canada: An Update.

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

STUDY

Medical error reduction: the effect of employee satisfaction with organizational support.

Lee D, Lee SM, Schniederjans MJ. Serv Ind J. 2011;31:1311-1325.

BOOK/REPORT

HealthGrades Sixth Annual Patient Safety in American Hospitals Study.

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

STUDY

Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project.

Fore AM, Sculli GL, Albee D, Neily J. J Nurs Manag. 2013;21:106-111.

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