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 (53)

•Diagnostic Errors (107)

•Identification Errors (52)

•Discontinuities, Gaps, and Hand-Off Problems (131)

•Fatigue and Sleep Deprivation (18)

•Medication Safety (484)

•Medical Complications (157)

•Nonsurgical Procedural Complications (25)

•Surgical Complications (188)

•Transfusion Complications (13)

•Psychological and Social Complications (28)

Origin/Sponsor

•Africa (3)

•Asia (34)

•Australia and New Zealand (58)

•Central and South America (8)

Resource Types

•Clinical Guideline (1)

•Journal Article (1121)

•Legislation/Regulation (4)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (31)

•Press Release/Announcement (3)

•Special or Theme Issue (2)

•Tools/Toolkit (1)

•Web Resource (9)

Error Types
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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (229)

•Legal and Policy Approaches (63)

•Error Reporting and Analysis (581)

•Communication Improvement (194)

•Human Factors Engineering (117)

•Teamwork (44)

•Specialization of Care (66)

•Logistical Approaches (86)

•Culture of Safety (104)

•Technologic Approaches (197)

•Education and Training (144)

Clinical Areas

•Allied Health Services (6)

Target Audience

•Health Care Providers (925)

•Health Care Executives and Administrators (1006)

•Non-Health Care Professionals (348)

•Patients (36)

Setting of Care

•Hospitals (865)

•Psychiatric Facilities (7)

•Residential Facilities (33)

•Ambulatory Care (155)

•Outpatient Surgery (17)

•Patient Transport (20)

1 - 20 of 1223

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COMMENTARY

Improving patient safety in radiotherapy by learning from near misses, incidents and errors.

Williams MV. Br J Radiol. 2007;80:297-301.

STUDY

Undiagnosed breast cancer at MR imaging: analysis of causes.

Pages EB, Millet I, Hoa D, Doyon FC, Taourel P. Radiology. 2012;264:40-50.

STUDY

Modern palliative radiation treatment: do complexity and workload contribute to medical errors?

D'Souza N, Holden L, Robson S, et al. Int J Radiat Oncol Biol Phys. 2012;84:e43-e48.

COMMENTARY

Accident prevention in day-to-day clinical radiation therapy practice.

Baeza M. Ann ICRP. 2012;41:179-187.

REVIEW

Clinical errors and medical negligence.

Oyebode F. Med Princ Pract. 2013 Jan 18; [Epub ahead of print].

STUDY

Paid malpractice claims for adverse events in inpatient and outpatient settings.

Bishop TF, Ryan AK, Casalino LP. JAMA. 2011;305:2427-2431.

STUDY

Venous thromboembolism after trauma: a never event?

Thorson CM, Ryan ML, Van Haren RM, et al. Crit Care Med. 2012;40:2967-2973.

STUDY

CT for suspected appendicitis in children: an analysis of diagnostic errors.

Taylor GA, Callahan MJ, Rodriguez D, Smink DS. Pediatr Radiol. 2006;36:331-337.

COMMENTARY

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

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

REVIEW

An international review of patient safety measures in radiotherapy practice.

Shafiq J, Barton M, Noble D, Lemer C, Donaldson LJ. Radiother Oncol. 2009;92:15-21.

STUDY

Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003.

Cook RI, Wreathall J, Smith A, et al. Transplantation. 2007;84:1602-1609.

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.

REVIEW

Systematic review of medication errors in pediatric patients.

Ghaleb MA, Barber N, Franklin BD, Yeung VW, Khaki ZF, Wong IC. Ann Pharmacother. 2006;40:1766-1776.

STUDY

Safety culture and complications after bariatric surgery.

Birkmeyer NJ, Finks JF, Greenberg CK, et al. Ann Surg. 2013;257:260-265.

STUDY

Surgical skill is predicted by the ability to detect errors.

Bann S, Khan M, Datta V, Darzi A. Am J Surg. 2005;189:412-415.

STUDY

Measuring perceptions of safety climate in primary care: a cross-sectional study.

de Wet C, Johnson P, Mash R, McConnachie A, Bowie P. J Eval Clin Pract. 2012;18:135-142.

BOOK/REPORT

Patient Safety.

Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.

BOOK/REPORT

Quarterly National Reporting and Learning System Data Summary.

National Patient Safety Agency. London, UK: National Health Service.

STUDY

Adverse events after screening and follow-up colonoscopy.

Rutter CM, Johnson E, Miglioretti DL, Mandelson MT, Inadomi J, Buist DSM. Cancer Causes Control. 2012;23:289-296.

STUDY

Factors associated with medication errors in the pediatric emergency department.

Vilà-de-Muga M, Colom-Ferrer L, Gonzàlez-Herrero M, Luaces-Cubells C. Pediatr Emerg Care. 2011;27:290-294.

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