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 (63)

•Diagnostic Errors (100)

•Identification Errors (57)

•Discontinuities, Gaps, and Hand-Off Problems (173)

•Fatigue and Sleep Deprivation (28)

•Medication Safety (565)

•Medical Complications (185)

•Nonsurgical Procedural Complications (21)

•Surgical Complications (206)

•Transfusion Complications (12)

•Psychological and Social Complications (36)

Origin/Sponsor

•Africa (2)

•Asia (34)

•Australia and New Zealand (45)

•Central and South America (4)

•Europe (224)

•North America (1086)

Resource Types

•Audiovisual (4)

•Book/Report (52)

•Clinical Guideline (1)

•Journal Article (1270)

•Legislation/Regulation (4)

•Meeting/Conference (2)

•Newspaper/Magazine Article (52)

•Press Release/Announcement (2)

•Special or Theme Issue (2)

•Tools/Toolkit (1)

•Web Resource (11)

Error Types
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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (250)

•Legal and Policy Approaches (74)

•Error Reporting and Analysis (607)

•Communication Improvement (236)

•Human Factors Engineering (130)

•Teamwork (40)

•Specialization of Care (81)

•Logistical Approaches (109)

•Culture of Safety (90)

•Technologic Approaches (241)

•Education and Training (164)

Clinical Areas

•Allied Health Services (2)

•Medicine (1136)

•Nursing (107)

•Pharmacy (214)

Target Audience

•Health Care Providers (952)

•Health Care Executives and Administrators (1090)

•Non-Health Care Professionals (389)

•Patients (57)

Setting of Care

•Hospitals (1044)

•Psychiatric Facilities (6)

•Residential Facilities (33)

•Ambulatory Care (177)

•Outpatient Surgery (23)

•Patient Transport (12)

1 - 20 of 1401

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REVIEW

Systematic review: association of shift length, protected sleep time, and night float with patient care, residents' health, and education.

Reed DA, Fletcher KE, Arora VM. Ann Intern Med. 2010;153:829-842.

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

Effects of the 2011 duty hour reforms on interns and their patients: a prospective longitudinal cohort study.

Sen S, Kranzler HR, Didwania AK, et al. JAMA Intern Med. 2013;173:657-662.

STUDY

Effect of a protected sleep period on hours slept during extended overnight in-hospital duty hours among medical interns: a randomized trial.

Volpp KG, Shea JA, Small DS, et al. JAMA. 2012;308:2208-2217.

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.

STUDY

Comparing two safety culture surveys: Safety Attitudes Questionnaire and Hospital Survey on Patient Safety.

Etchegaray JM, Thomas EJ. BMJ Qual Saf. 2012;21:490-498.

STUDY

Outcomes of care by hospitalists, general internists, and family physicians.

Lindenauer PK, Rothberg MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD. N Engl J Med. 2007;357:2589-2600.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

STUDY

Improving the discharge process by embedding a discharge facilitator in a resident team.

Finn KM, Heffner R, Chang Y, et al. J Hosp Med. 2011;6:494-500.

STUDY

Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial.

Shorr RI, Chandler AM, Mion LC, et al. Ann Intern Med. 2012;157:692-699.

STUDY

The association between night or weekend admission and hospitalization-relevant patient outcomes.

Khanna R, Wachsberg K, Marouni A, Feinglass J, Williams MV, Wayne DB. J Hosp Med. 2011;6:10-14.

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.

NEWSPAPER/MAGAZINE ARTICLE

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

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

STUDY

Differences in outcomes between ICU attending and senior resident physician led medical emergency team responses.

Morris DS, Schweickert W, Holena D, et al. Resuscitation. 2012;83:1434-1437.

STUDY

Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance.

Classen DC, Jaser L, Budnitz DS. Jt Comm J Qual Patient Saf. 2010;36:12-21, AP1-AP9.

STUDY

Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment and mortality.

McKinney JS, Deng Y, Kasner SE, Kostis JB; Myocardial Infarction Data Acquisition System (MIDAS 15) Study Group. Stroke. 2011;42:2403-2409.

STUDY

Vital sign abnormalities, rapid response, and adverse outcomes in hospitalized patients.

Fagan K, Sabel A, Mehler PS, MacKenzie TD. Am J Med Qual. 2012;27:480-486.

STUDY

Multiple patient safety events within a single hospitalization: a national profile in US hospitals.

Yu H, Greenberg MD, Haviland AM, Farley DO. Am J Med Qual. 2012;27:472-479.

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.

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