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 (56)

•Discontinuities, Gaps, and Hand-Off Problems (179)

•Fatigue and Sleep Deprivation (28)

•Medication Safety (635)

•Medical Complications (201)

•Nonsurgical Procedural Complications (26)

•Surgical Complications (232)

•Transfusion Complications (14)

•Psychological and Social Complications (38)

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•Africa (3)

•Asia (44)

•Australia and New Zealand (64)

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Resource Types

•Audiovisual (4)

•Book/Report (51)

•Clinical Guideline (1)

•Journal Article (1415)

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•Meeting/Conference (2)

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•Press Release/Announcement (2)

•Special or Theme Issue (4)

•Tools/Toolkit (1)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (289)

•Legal and Policy Approaches (77)

•Error Reporting and Analysis (666)

•Communication Improvement (250)

•Human Factors Engineering (139)

•Teamwork (48)

•Specialization of Care (96)

•Logistical Approaches (102)

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•Technologic Approaches (275)

•Education and Training (187)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (1062)

•Health Care Executives and Administrators (1224)

•Non-Health Care Professionals (458)

•Patients (59)

Setting of Care

•Hospitals (1142)

•Psychiatric Facilities (7)

•Residential Facilities (33)

•Ambulatory Care (179)

•Outpatient Surgery (24)

•Patient Transport (16)

1 - 20 of 1549

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STUDY

Needlestick injuries among surgeons in training.

Makary MA, Al-Attar A, Holzmueller CG, et al. N Engl J Med. 2007;356:2693-2699.

STUDY

Preventable morbidity at a mature trauma center.

Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.

STUDY

Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.

Vermaire D, Caruso MC, Lesko A, et al. BMJ Qual Saf. 2011;20:895-902.

STUDY

Adverse event reporting: lessons learned from 4 years of Florida office data.

Coldiron B, Fisher AH, Adelman E, et al. Dermatol Surg. 2005;31(pt 1):1079-1092; discussion 1093.

STUDY

Patient harm in general surgery--a prospective study.

Kaul AK, McCulloch PG. J Patient Saf. 2007;3:22-26.

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.

COMMENTARY

Miles to go: an introduction to the 5 Million Lives Campaign.

McCannon CJ, Hackbarth AD, Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:477-484.

STUDY

The association between frequency of self-reported medical errors and anesthesia trainee supervision: a survey of United States anesthesiology residents-in-training.

De Oliveira GS Jr, Rahmani R, Fitzgerald PC, Chang R, McCarthy RJ. Anesth Analg. 2013;116:892-897.

STUDY

Prevention of medical accidents caused by defective surgical instruments.

Yasuhara H, Fukatsu K, Komatsu T, Obayashi T, Saito Y, Uetera Y. Surgery. 2012;151:153-161.

STUDY

Nurse reports of adverse events during sedation procedures at a pediatric hospital.

Lightdale JR, Mahoney LB, Fredette ME, Valim C, Wong S, DiNardo JA. J Perianesth Nurs. 2009;24:300-306.

STUDY

The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use.

Page RL 2nd, Ruscin JM. Am J Geriatr Pharmacother. 2006;4:297-305.

COMMENTARY

What happens when things go wrong?

Brandom BW, Callahan P, Micalizzi DA. Paediatr Anaesth. 2011;21:730-736.

COMMENTARY

Residents' duty hours—toward an empirical narrative.

Rosenbaum L, Lamas D. N Engl J Med. 2012;367:2044-2049.

NEWSPAPER/MAGAZINE ARTICLE

Medication administration in anesthesia: time for a paradigm shift.

Stabile M, Webster CS, Merry AF. APSF Newsletter. Fall 2007;22:44-47.

STUDY

Determinants of adverse events in vascular surgery.

Hernandez-Boussard T, McDonald KM, Morton JM, Dalman RL, Bech FR. J Am Coll Surg. 2012;214:788-797.

STUDY

Auroy Y, Benhamou D, Péquignot F, Bovet M, Jougla E, Lienhart A. Anaesthesia. 2009;64:366-370.

STUDY

Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program.

Kiran RP, Ahmed Ali U, Coffey JC, Vogel JD, Pokala N, Fazio VW. Ann Surg. 2012;256:469-475.

STUDY

Voluntary electronic reporting of laboratory errors: an analysis of 37,532 laboratory event reports from 30 health care organizations.

Snydman LK, Harubin B, Kumar S, Chen J, Lopez RE, Salem DN. Am J Med Qual. 2012;27:147-153.

STUDY

A multicenter, phased, cluster-randomized controlled trial to reduce central line–associated bloodstream infections in intensive care units.

Marsteller JA, Sexton JB, Hsu YJ, et al. Crit Care Med. 2012;40:2933-2939.

STUDY

Relationship between patient complaints and surgical complications.

Murff HJ, France DJ, Blackford J, et al. Qual Saf Health Care. 2006;15:13-16.

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