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 (69)

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•Identification Errors (59)

•Discontinuities, Gaps, and Hand-Off Problems (170)

•Fatigue and Sleep Deprivation (27)

•Medication Safety (619)

•Medical Complications (195)

•Nonsurgical Procedural Complications (24)

•Surgical Complications (214)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (263)

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•Error Reporting and Analysis (656)

•Communication Improvement (241)

•Human Factors Engineering (135)

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Clinical Areas

•Allied Health Services (6)

Target Audience

•Health Care Providers (1059)

•Health Care Executives and Administrators (1167)

•Non-Health Care Professionals (439)

•Patients (63)

Setting of Care

•Hospitals (1058)

•Psychiatric Facilities (7)

•Residential Facilities (41)

•Ambulatory Care (186)

•Outpatient Surgery (21)

•Patient Transport (18)

1 - 20 of 1485

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STUDY

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.

COMMENTARY

Smart pumps: advanced capabilities and continuous quality improvement.

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

STUDY

Risk of adverse drug events in neonates treated with opioids and the effect of a bar-code–assisted medication administration system.

Morriss FH, Jr, Abramowitz PW, Nelson SP, Milavetz G, Michael SL, Gordon SN. Am J Health Syst Pharm. 2011;68:57-62.

STUDY

Smartphone use during inpatient attending rounds: prevalence, patterns and potential for distraction.

Katz-Sidlow RJ, Ludwig A, Miller S, Sidlow R. J Hosp Med. 2012;7:595-599.

STUDY

Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study.

Sinopoli DJ, Needham DM, Thompson DA, et al. J Crit Care. 2007;22:177-183.

STUDY

Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii.

Lin DM, Weeks K, Holzmueller CG, Pronovost PJ, Pham JC. Jt Comm J Qual Patient Saf. 2013;39:51-60.

STUDY

Provider and pharmacist responses to warfarin drug–drug interaction alerts: a study of healthcare downstream of CPOE alerts.

Miller AM, Boro MS, Korman NE, Davoren JB. J Am Med Inform Assoc. 2011;18(suppl 1):i45-i50.

STUDY

Eradicating central line–associated bloodstream infections statewide: the Hawaii experience.

Lin DM, Weeks K, Bauer L, et al. Am J Med Qual. 2012;27:124-129.

STUDY

Intensive care unit readmissions in U.S. hospitals: patient characteristics, risk factors, and outcomes.

Kramer AA, Higgins TL, Zimmerman JE. Crit Care Med. 2012;40:3-10.

STUDY

Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study.

Morriss FH Jr, Abramowitz PW, Nelson SP, et al. J Pediatr. 2009;197:678-685.

STUDY

Intervention to reduce transmission of resistant bacteria in intensive care.

Huskins WC, Huckabee CM, O'Grady NP, et al; STAR*ICU Trial Investigators. N Engl J Med. 2011;364:1407-1418.

STUDY

Reevaluating recovery: perceived violations and preemptive interventions on emergency psychiatry rounds.

Cohen T, Blatter B, Almeida C, Patel VL. J Am Med Inform Assoc. 2007;14:312-319.

STUDY

Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: business case for quality improvement.

Nowak JE, Brilli RJ, Lake MR, et al. Pediatr Crit Care Med. 2010;11:579-587.

STUDY

Adverse drug event reporting in intensive care units: a survey of current practices.

Kane-Gill SL, Devlin JW. Ann Pharmacother. 2006;40:1267-73.

STUDY

Cost implications of actual and potential adverse events prevented by interventions of a critical care pharmacist.

Kopp BJ, Mrsan M, Erstad BL, Duby JJ. Am J Health Syst Pharm. 2007;64:2483-2487.

STUDY

Multiprofessional survey of protocol use in the intensive care unit.

LeBlanc JM, Kane-Gill SL, Pohlman AS, Herr DL. J Crit Care. 2012;27:738.e9-738.e17.

STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

STUDY

Programmable infusion pumps in ICUs: an analysis of corresponding adverse drug events.

Nuckols TK, Bower AG, Paddock SM, et al. J Gen Intern Med. 2008;23(suppl 1):41-45.

STUDY

Analysis of risk factors for adverse drug events in critically ill patients.

Kane-Gill SL, Kirisci L, Verrico MM, Rothschild JM. Crit Care Med. 2012;40:823-828.

STUDY

Intensive care units, communication between nurses and physicians, and patients' outcomes.

Manojlovich M, Antonakos CL, Ronis DL. Am J Crit Care. 2009;18:21-30.

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