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 (41)

•Diagnostic Errors (86)

•Identification Errors (34)

•Discontinuities, Gaps, and Hand-Off Problems (186)

•Fatigue and Sleep Deprivation (24)

•Medication Safety (427)

•Medical Complications (154)

•Nonsurgical Procedural Complications (15)

•Surgical Complications (126)

•Transfusion Complications (7)

•Psychological and Social Complications (29)

Origin/Sponsor

•Africa (4)

•Asia (35)

•Australia and New Zealand (60)

•Central and South America (4)

Resource Types

•Clinical Guideline (1)

•Journal Article (999)

•Legislation/Regulation (4)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (38)

•Press Release/Announcement (1)

•Special or Theme Issue (4)

•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 (196)

•Legal and Policy Approaches (70)

•Error Reporting and Analysis (493)

•Communication Improvement (216)

•Human Factors Engineering (78)

•Teamwork (23)

•Specialization of Care (64)

•Logistical Approaches (75)

•Culture of Safety (75)

•Technologic Approaches (180)

•Education and Training (128)

Clinical Areas

•Allied Health Services (6)

•Medicine (902)

•Nursing (73)

•Pharmacy (163)

Target Audience

•Health Care Providers (780)

•Health Care Executives and Administrators (870)

•Non-Health Care Professionals (311)

•Patients (49)

Setting of Care

•Hospitals (866)

•Psychiatric Facilities (4)

•Residential Facilities (21)

•Ambulatory Care (142)

•Outpatient Surgery (16)

•Patient Transport (9)

1 - 20 of 1115

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STUDY

What do patients think about year-end resident continuity clinic handoffs?: a qualitative study.

Pincavage AT, Lee WW, Beiting KJ, Arora VM. J Gen Intern Med. 2013 Apr 18; [Epub ahead of print].

STUDY

Introduction of discharge plan to reduce adverse events within 72 hours of discharge from the ICU.

Williams TA, Leslie GD, Elliott N, Brearley L, Dobb GJ. J Nurs Care Qual. 2010;25:73-79.

STUDY

Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods.

Payne CE, Stein JM, Leong T, Dressler DD. BMJ Qual Saf. 2012;21:925-932.

STUDY

The care transitions intervention: translating from efficacy to effectiveness.

Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. Arch Intern Med. 2011;171:1232-1237.

STUDY

Health information technology and its effects on hospital costs, outcomes, and patient safety.

Encinosa WE, Bae J. Inquiry. Winter 2011/2012;48:288-303.

STUDY

Use of an appreciative inquiry approach to improve resident sign-out in an era of multiple shift changes.

Helms AS, Perez TE, Baltz J, et al. J Gen Intern Med. 2012;27:287-291.

STUDY

The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients.

Encinosa WE, Hellinger FJ. Health Serv Res. 2008;43:2067-2085.

STUDY

Consequences of inadequate sign-out for patient care.

Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Arch Intern Med. 2008;168:1755-1760.

STUDY

Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia.

Bismark MM, Spittal MJ, Gurrin LC, Ward M, Studdert DM. BMJ Qual Saf. 2013;22:532-540.

STUDY

Indication-based prescribing prevents wrong-patient medication errors in computerized provider order entry (CPOE).

Galanter W, Falck S, Burns M, Laragh M, Lambert BL. J Am Med Inform Assoc. 2013;20:477-481.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.

BOOK/REPORT

Eliminating CLABSI: A National Patient Safety Imperative.

Rockville, MD: Agency for Healthcare Research and Quality; September 2011. AHRQ Publication No. 11-0037-1-EF.

STUDY

A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths.

de Feijter JM, de Grave WS, Muijtjens AM, Scherpbier AJ, Koopmans RP. PLoS One. 2012;7:e31125.

NEWSPAPER/MAGAZINE ARTICLE

Patients taking their own medications while in the hospital.

PA-PSRS Patient Saf Advis. June 2012;9:50-57.

STUDY

Language barriers and understanding of hospital discharge instructions.

Karliner LS, Auerbach A, Nápoles A, Schillinger D, Nickleach D, Pérez-Stable EJ. Med Care. 2012;50:283-289.

COMMENTARY

Quality improvement through implementation of discharge order reconciliation.

Lu Y, Clifford P, Bjorneby A, et al. Am J Health Syst Pharm. 2013;70:815-820.

STUDY

Potentially inappropriate medications in a large cohort of patients in geriatric units: association with clinical and functional characteristics.

Fromm MF, Maas R, Tümena T, Gaßmann KG. Eur J Clin Pharmacol. 2013;69:975-984.

STUDY

Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist.

Greenstein EA, Arora VM, Staisiunas PG, Banerjee SS, Farnan JM. BMJ Qual Saf. 2013;22:219-224.

STUDY

Exploring relationships between patient safety culture and patients' assessments of hospital care.

Sorra J, Khanna K, Dyer N, Mardon R, Famolaro T. J Patient Saf. 2012;8:131-139.

STUDY

Hospital patients' reports of medical errors and undesirable events in their health care.

Davis RE, Sevdalis N, Neale G, Massey R, Vincent CA. J Eval Clin Pract. 2012 Jun 12; [Epub ahead of print].

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