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 (73)

•Diagnostic Errors (112)

•Identification Errors (60)

•Discontinuities, Gaps, and Hand-Off Problems (191)

•Fatigue and Sleep Deprivation (28)

•Medication Safety (629)

•Medical Complications (203)

•Nonsurgical Procedural Complications (24)

•Surgical Complications (217)

•Transfusion Complications (13)

•Psychological and Social Complications (36)

Origin/Sponsor

•Africa (3)

•Asia (39)

•Australia and New Zealand (64)

•Central and South America (8)

•Europe (279)

•North America (1117)

Resource Types

•Audiovisual (4)

•Book/Report (49)

•Journal Article (1389)

•Legislation/Regulation (4)

•Meeting/Conference (2)

•Newspaper/Magazine Article (53)

•Press Release/Announcement (2)

•Special or Theme Issue (3)

•Tools/Toolkit (1)

•Web Resource (13)

Error Types
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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (278)

•Legal and Policy Approaches (75)

•Error Reporting and Analysis (645)

•Communication Improvement (255)

•Human Factors Engineering (139)

•Teamwork (48)

•Specialization of Care (98)

•Logistical Approaches (102)

•Culture of Safety (101)

•Technologic Approaches (276)

•Education and Training (185)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (1034)

•Health Care Executives and Administrators (1217)

•Non-Health Care Professionals (457)

•Patients (60)

Setting of Care

•Hospitals (1126)

•Psychiatric Facilities (6)

•Residential Facilities (36)

•Ambulatory Care (171)

•Outpatient Surgery (25)

•Patient Transport (18)

1 - 20 of 1520

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STUDY

Insufficient communication about medication use at the interface between hospital and primary care.

Glintborg B, Andersen SE, Dalhoff K. Qual Saf Health Care. 2007;16:34-39.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.

Oakbrook Terrace, IL: The Joint Commission; January 2010.

STUDY

A 5-year analysis of rapid response system activation at an in-hospital haemodialysis unit.

Galhotra S, Devita MA, Dew MA, Simmons RL. Qual Saf Health Care. 2010;19:e38.

STUDY

The safety of hospital stroke care.

Holloway RG, Tuttle D, Baird T, Skelton WK. Neurology. 2007;68:550-555.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2007.

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

STUDY

Nursing home error and level of staff credentials.

Scott-Cawiezell J, Pepper GA, Madsen RW, Petroski G, Vogelsmeier A, Zellmer D. Clin Nurs Res. 2007;16:72-78.

BOOK/REPORT

Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events.

Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; October 2011. Report No. OEI-01-08-00590.

STUDY

Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?

Seiden SC, Barach P. Arch Surg. 2006;141:931-939.

MEETING/CONFERENCE PROCEEDINGS

Safety in the NICU: preventing medical errors.

Stokowski LA. Highlights of the National Association of Neonatal Nurses 22nd Annual Conference [Medscape.com]. March 8, 2007.

REVIEW

Patient safety in dermatology: a review of the literature.

Cao LY, Taylor JS, Vidimos A. Dermatol Online J. 2010;16:3.

COMMENTARY

Eliminating preventable death at Ascension Health.

Tolchin S, Brush R, Lange P, Bates P, Garbo JJ. Jt Comm J Qual Patient Saf. 2007;33:145-154.

STUDY

Medication reconciliation and hypertension control.

Persell SD, Bailey SC, Tang J, Davis TC, Wolf MS. Am J Med. 2010;123:182.e9-182.e15.

STUDY

Patient safety measures in burn care: do national reporting systems accurately reflect quality of burn care?

Mandell SP, Robinson EF, Cooper CL, Klein MB, Gibran NS. J Burn Care Res. 2010;31:125-129.

STUDY

Getting doctors to report medical errors: project DISCLOSE.

King ES, Moyer DV, Couturie MJ, Gaughan JP, Shulkin DJ. Jt Comm J Qual Patient Saf. 2006;32:382-392.

STUDY

Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals.

Feigenbaum P, Neuwirth E, Trowbridge L, et al. Med Care. 2012;50:599-605.

STUDY

Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers.

Kachalia A, Gandhi TK, Puopolo AL, et al. Ann Emerg Med. Ann Emerg Med. 2007;49:196-205.

STUDY

Internal medicine trainees' views of training adequacy and duty hours restrictions in 2009.

Shea JA, Weissman A, McKinney S, Silber JH, Volpp KG. Acad Med. 2012;87:889-894.

STUDY

Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths.

Gruen RL, Jurkovich GJ, McIntyre LK, Foy HM, Maier RV. Ann Surg. 2006;244:371-380.

STUDY

Ambulance personnel perceptions of near misses and adverse events in pediatric patients.

Cushman JT, Fairbanks RJ, O'Gara KG, et al. Prehosp Emerg Care. 2010;14:477-484.

STUDY

Surveillance of medical device-related hazards and adverse events in hospitalized patients.

Samore MH, Evans RS, Lassen A, et al. JAMA. 2004;291:325-334.

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