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 (21)

•Diagnostic Errors (67)

•Identification Errors (22)

•Discontinuities, Gaps, and Hand-Off Problems (61)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (246)

•Medical Complications (53)

•Nonsurgical Procedural Complications (15)

•Surgical Complications (97)

•Transfusion Complications (6)

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•Asia (19)

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•Book/Report (18)

•Journal Article (596)

•Newspaper/Magazine Article (13)

•Press Release/Announcement (2)

•Special or Theme Issue (2)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (87)

•Legal and Policy Approaches (27)

•Error Reporting and Analysis (438)

•Communication Improvement (70)

•Human Factors Engineering (54)

•Teamwork (18)

•Specialization of Care (31)

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Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (399)

•Health Care Executives and Administrators (533)

•Non-Health Care Professionals (140)

•Patients (7)

Setting of Care

•Hospitals (438)

•Psychiatric Facilities (3)

•Residential Facilities (13)

•Ambulatory Care (71)

•Outpatient Surgery (6)

•Patient Transport (7)

1 - 20 of 634

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STUDY

Adverse events detected by clinical surveillance on an obstetric service.

Forster AJ, Fung I, Caughey S, et al. Obstet Gynecol. 2006;108:1073-1083.

REVIEW

Near miss audit in obstetrics.

Penney G, Brace V. Curr Opin Obstet Gynecol. 2007;19:145-150.

STUDY

Are the Agency for Healthcare Research and Quality obstetric trauma indicators valid measures of hospital safety?

Grobman WA, Feinglass J, Murthy S. Am J Obstet Gynecol. 2006;195:868-874.

REVIEW

Medication errors in older people with mental health problems: a review.

Maidment ID, Haw C, Stubbs J, Fox C, Katona C, Franklin BD. Int J Geriatr Psychiatry. 2008;23:564-573.

STUDY

Surgical skill is predicted by the ability to detect errors.

Bann S, Khan M, Datta V, Darzi A. Am J Surg. 2005;189:412-415.

STUDY

A national survey of safe practice with epidural analgesia in obstetric units.

Jones R, Swales HA, Lyons GR. Anaesthesia. 2008;63:516-519.

STUDY

Cause and effect analysis of closed claims in obstetrics and gynecology.

White AA, Pichert JW, Bledsoe SH, Irwin C, Entman SS. Obstet Gynecol. 2005;105:1031-1038.

STUDY

The social dimensions of safety incident reporting in maternity care: the influence of working relationships and group processes.

Lindsay P, Sandall J, Humphrey C. Soc Sci Med. 2012;75:1793-1799.

STUDY

The introduction of a surgical safety checklist in a tertiary referral obstetric centre.

Kearns RJ, Uppal V, Bonner J, Robertson J, Daniel M, McGrady EM. BMJ Qual Saf. 2011;20:818-822.

STUDY

A series of anesthesia-related maternal deaths in Michigan, 1985-2003.

Mhyre JM, Riesner MN, Polley LS, Naughton NN. Anesthesiology. 2007;106:1096-1104.

COMMENTARY

Hidden danger, obvious opportunity: error and risk in the management of cancer.

Munro AJ. Br J Radiol. 2007;80:955-966.

STUDY

A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients.

Watkinson PJ, Barber VS, Price JD, et al. Anaesthesia. 2006;61:1031-1039.

REVIEW

Clinical errors and medical negligence.

Oyebode F. Med Princ Pract. 2013 Jan 18; [Epub ahead of print].

STUDY

Using human error theory to explore the supply of non-prescription medicines from community pharmacies.

Watson MC, Bond CM, Johnston M, Mearns K. Qual Saf Health Care. 2006;15:244-250.

STUDY

Liability associated with obstetric anesthesia: a closed claims analysis.

Davies JM, Posner KL, Lee LA, Cheney FW, Domino KB. Anesthesiology. 2009;110:131-139.

STUDY

Intralipid medication errors in the neonatal intensive care unit.

Chuo J, Lambert G, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:104-111.

STUDY

Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review.

Sari AB, Sheldon TA, Cracknell A, Turnbull A. BMJ. 2007;334;79.

STUDY

Preventable deaths in patients admitted from emergency department.

Lu T-C, Tsai C-L, Lee C-C, et al. Emerg Med J. 2006;23:452-455.

STUDY

How dangerous is a day in hospital?: A model of adverse events and length of stay for medical inpatients.

Hauck K, Zhao X. Med Care. 2011;49:1068-1075.

REVIEW

Will my patient fall?

Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. JAMA. 2007;297:77-86.

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