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 (76)

•Diagnostic Errors (118)

•Identification Errors (60)

•Discontinuities, Gaps, and Hand-Off Problems (177)

•Fatigue and Sleep Deprivation (28)

•Medication Safety (622)

•Medical Complications (196)

•Nonsurgical Procedural Complications (24)

•Surgical Complications (212)

•Transfusion Complications (12)

•Psychological and Social Complications (35)

Origin/Sponsor

•Africa (2)

•Asia (38)

•Australia and New Zealand (53)

•Central and South America (9)

•Europe (261)

•North America (1094)

Resource Types

•Audiovisual (4)

•Book/Report (41)

•Journal Article (1348)

•Legislation/Regulation (3)

•Meeting/Conference (1)

•Newspaper/Magazine Article (53)

•Press Release/Announcement (3)

•Special or Theme Issue (2)

•Tools/Toolkit (1)

•Web Resource (8)

Error Types
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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (269)

•Legal and Policy Approaches (68)

•Error Reporting and Analysis (603)

•Communication Improvement (250)

•Human Factors Engineering (147)

•Teamwork (50)

•Specialization of Care (95)

•Logistical Approaches (106)

•Culture of Safety (105)

•Technologic Approaches (267)

•Education and Training (186)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (1015)

•Health Care Executives and Administrators (1166)

•Non-Health Care Professionals (432)

•Patients (50)

Setting of Care

•Hospitals (1059)

•Psychiatric Facilities (7)

•Residential Facilities (36)

•Ambulatory Care (172)

•Outpatient Surgery (21)

•Patient Transport (19)

1 - 20 of 1464

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COMMENTARY

Unreported errors in the intensive care unit: a case study of the way we work.

Henneman EA. Crit Care Nurse. 2007;27:27-34.

STUDY

Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration.

Yamamoto L, Kanemori J. Am J Emerg Med. 2010;28:588-592.

STUDY

Medical errors recovered by critical care nurses.

Dykes PC, Rothschild JM, Hurley AC. J Nurs Adm. 2010;40:241-246.

STUDY

Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork.

Vogelsmeier A, Scott-Cawiezell J. J Nurs Care Qual. 2011;26:236-242.

STUDY

Relationship between systems-level factors and hand hygiene adherence.

Dunn-Navarra AM, Cohen B, Stone PW, Pogorzelska M, Jordan S, Larson E. J Nurs Care Qual. 2011;26:30-38.

STUDY

Effect of an anonymous reporting system on near-miss and harmful medical error reporting in a pediatric intensive care unit.

Grant MJ, Larsen GY. J Nurs Care Qual. 2007;22:213-221.

STUDY

Toward learning from patient safety reporting systems.

Pronovost PJ, Thompson DA, Holzmueller CG, et al. J Crit Care. 2006;21:305-315.

STUDY

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit.

Stavroudis TA, Shore AD, Morlock L, Hicks RW, Bundy D, Miller MR. J Perinatol. 2010;30:459-468.

COMMENTARY

Medical devices and patient safety.

Mattox E. Crit Care Nurse. August 2012;32:60-68.

STUDY

Role of registered nurses in error prevention, discovery and correction.

Rogers AE, Dean GE, Hwang WT, Scott LD. Qual Saf Health Care. 2008;17:117-121.

STUDY

Challenges in posthospital care: nurses as coaches for medication management.

Costa LL, Poe SS, Lee MC. J Nurs Care Qual. 2011;26:243-251.

REVIEW

Work interruptions and their contribution to medication administration errors: an evidence review.

Biron AD, Loiselle CG, Lavoie-Tremblay M. Worldviews Evid Based Nurs. 2009;6:70-86.

STUDY

Impact of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: a cluster randomised trial.

Huis A, Schoonhoven L, Grol R, Donders R, Hulscher M, van Achterberg T. Int J Nurs Stud. 2013;50:464-474.

STUDY

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.

BOOK/REPORT

Improving America's Hospitals: A Report on Quality and Safety.

Oakbrook Terrace, IL: The Joint Commission; March 2007.

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.

STUDY

Implementation of Condition Help: family teaching and evaluation of family understanding.

Hueckel RM, Mericle JM, Frush K, Martin PL, Champagne MT. J Nurs Care Qual. 2012;27:176-181.

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.

STUDY

Antecedents of severe and nonsevere medication errors.

Chang YK, Mark BA. J Nurs Scholarsh. 2009;41:70-78.

STUDY

Are temporary staff associated with more severe emergency department medication errors?

Pham JC, Andrawis M, Shore AD, Fahey M, Morlock L, Pronovost PJ. J Healthc Qual. 2011;33:9-18.

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