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 (107)

•Identification Errors (54)

•Discontinuities, Gaps, and Hand-Off Problems (162)

•Fatigue and Sleep Deprivation (28)

•Medication Safety (560)

•Medical Complications (180)

•Nonsurgical Procedural Complications (21)

•Surgical Complications (184)

•Transfusion Complications (11)

•Psychological and Social Complications (35)

Origin/Sponsor

•Africa (3)

•Asia (34)

•Australia and New Zealand (49)

•Central and South America (6)

•Europe (207)

•North America (1083)

Resource Types

•Audiovisual (4)

•Book/Report (56)

•Clinical Guideline (1)

•Journal Article (1243)

•Legislation/Regulation (4)

•Meeting/Conference (2)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (50)

•Press Release/Announcement (3)

•Special or Theme Issue (4)

•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 (242)

•Legal and Policy Approaches (79)

•Error Reporting and Analysis (632)

•Communication Improvement (219)

•Human Factors Engineering (117)

•Teamwork (38)

•Specialization of Care (81)

•Logistical Approaches (100)

•Culture of Safety (94)

•Technologic Approaches (230)

•Education and Training (182)

Clinical Areas

•Allied Health Services (6)

•Medicine (1086)

•Nursing (113)

•Pharmacy (210)

Target Audience

•Health Care Providers (947)

•Health Care Executives and Administrators (1067)

•Non-Health Care Professionals (391)

•Patients (58)

Setting of Care

•Hospitals (995)

•Psychiatric Facilities (7)

•Residential Facilities (40)

•Ambulatory Care (170)

•Outpatient Surgery (21)

•Patient Transport (16)

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COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

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

STUDY

Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians.

Davidenko JM, Snyder LS. J Electrocardiol. 2007;40:450-457.

STUDY

Hospital workload and adverse events.

Weissman JS, Rothschild JM, Bendavid E, et al. Med Care. 2007;45:448-455.

STUDY

Factors influencing perioperative nurses' error reporting preferences.

Espin S, Regehr G, Levinson W, Baker GR, Biancucci C, Lingard L. AORN J. 2007;85:527-528, 530-532, 534-536, 539-543.

STUDY

Large-scale deployment of the Global Trigger Tool across a large hospital system: refinements for the characterisation of adverse events to support patient safety learning opportunities.

Good VS, Saldaña M, Gilder R, Nicewander D, Kennerly DA. BMJ Qual Saf. 2011;20:25-30.

COMMENTARY

Establishing a culture for patient safety - the role of education.

Milligan FJ. Nurse Educ Today. 2007;27:95-102.

STUDY

Outside case review of surgical pathology for referred patients: the impact on patient care.

Swapp RE, Aubry MC, Salomão DR, Cheville JC. Arch Pathol Lab Med. 2013;137:233-240.

STUDY

Impact of diagnosis-timing indicators on measures of safety, comorbidity, and case mix groupings from administrative data sources.

Naessens JM, Campbell CR, Berg B, Williams AR, Culbertson R. Med Care. 2007;45:781-788.

COMMENTARY

Using incident reporting to improve patient safety: a conceptual model.

Pronovost PJ, Holzmueller CG, Young J, et al. J Patient Saf. 2007;3:27-33.

STUDY

Cognitive errors detected in anaesthesiology: a literature review and pilot study.

Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Br J Anaesth. 2012;108:229-235.

STUDY

Attitudes toward medical device use errors and the prevention of adverse events.

Johnson TR, Tang X, Graham MJ, et al. Jt Comm J Qual Patient Saf. 2007;33:689-694.

REVIEW

Twenty-four/seven: a mixed-method systematic review of the off-shift literature.

de Cordova PB, Phibbs CS, Bartel AP, Stone PW. J Adv Nurs. 2012;68:1454-1468.

NEWSPAPER/MAGAZINE ARTICLE

Medication errors: when pharmacy is closed.

PA-PSRS Patient Saf Advis. March 2012;9:11-17.

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.

COMMENTARY

Smart pumps: advanced capabilities and continuous quality improvement.

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

STUDY

Economic measurement of medical errors using a hospital claims database.

David G, Gunnarsson CL, Waters HC, Horblyuk R, Kaplan HS. Value Health. 2013;16:305-310.

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

The rate and costs attributable to intravenous patient-controlled analgesia errors.

Meissner B, Nelson W, Hicks R, Sikirica V, Gagne J, Schein J. Hosp Pharm. 2009;44:312–324.

STUDY

On higher ground: ethical reasoning and its relationship with error disclosure.

Cole AP, Block L, Wu AW. BMJ Qual Saf. 2013 Mar 1; [Epub ahead of print].

STUDY

Contemporary evidence about hospital strategies for reducing 30-day readmissions: a national study.

Bradley EH, Curry L, Horwitz LI, et al. J Am Coll Cardiol. 2012;60:607-614.

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