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 (71)

•Identification Errors (41)

•Discontinuities, Gaps, and Hand-Off Problems (134)

•Fatigue and Sleep Deprivation (24)

•Medication Safety (413)

•Medical Complications (146)

•Nonsurgical Procedural Complications (14)

•Surgical Complications (204)

•Transfusion Complications (9)

•Psychological and Social Complications (25)

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•Africa (2)

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Resource Types

•Journal Article (965)

•Legislation/Regulation (3)

•Meeting/Conference (2)

•Newspaper/Magazine Article (46)

•Press Release/Announcement (1)

•Special or Theme Issue (2)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (189)

•Legal and Policy Approaches (60)

•Error Reporting and Analysis (461)

•Communication Improvement (174)

•Human Factors Engineering (97)

•Teamwork (33)

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•Technologic Approaches (192)

•Education and Training (129)

Clinical Areas

•Allied Health Services (2)

•Medicine (866)

•Nursing (85)

•Pharmacy (161)

Target Audience

•Health Care Providers (741)

•Health Care Executives and Administrators (811)

•Non-Health Care Professionals (303)

•Patients (47)

Setting of Care

•Hospitals (757)

•Psychiatric Facilities (4)

•Residential Facilities (30)

•Ambulatory Care (134)

•Outpatient Surgery (23)

•Patient Transport (12)

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COMMENTARY

Learning from adverse events and near misses.

Greenberg CC. J Gastrointest Surg. 2008;13:3-5.

STUDY

Infection control assessment of ambulatory surgical centers.

Schaefer MK, Jhung M, Dahl M, et al. JAMA. 2010;303:2273-2279.

STUDY

Quantifying and characterizing adverse events in dermatologic surgery.

O'Neill JL, Lee YS, Solomon JA, et al. Dermatol Surg. 2013 Mar 6; [Epub ahead of print].

STUDY

Determining the safety of office-based surgery: what 10 years of Florida data and 6 years of Alabama data reveal.

Starling J III, Thosani MK, Coldiron BM. Dermatol Surg. 2012;38:171-177.

STUDY

Errors with concentrated epinephrine in otolaryngology.

Shah RK, Hoy E, Roberson DW, Nielsen D. Laryngoscope. 2008 Nov; 118: 1928-30.

STUDY

Resident participation does not affect surgical outcomes, despite introduction of new techniques.

Patel SP, Gauger PG, Brown DL, Englesbe MJ, Cederna PS. J Am Coll Surg. 2010;211:540-545.

STUDY

Cardiac surgery errors: results from the UK National Reporting and Learning System.

Martinez EA, Shore A, Colantuoni E, et al. Int J Qual Health Care. 2011;23:151-158.

BOOK/REPORT

Medmarx Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005.

Rockville, MD: United States Pharmacopeia; 2007.

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

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.

BOOK/REPORT

Utah Tenth Anniversary (2001–2011) Patient Safety Report: Identifying Opportunities for Improvement.

Salt Lake City, UT: Utah Department of Health, HealthInsight, Utah Hospital Association; 2012.

BOOK/REPORT

HealthGrades Sixth Annual Patient Safety in American Hospitals Study.

Golden, CO: HealthGrades, Inc.; April 2009.

STUDY

The influence of resident involvement on surgical outcomes.

Raval MV, Wang X, Cohen ME, et al. J Am Coll Surg. 2011;212:889-898.

STUDY

Safety culture and complications after bariatric surgery.

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

STUDY

Pediatric antidepressant medication errors in a national error reporting database.

Rinke ML, Bundy DG, Shore AD, Colantuoni E, Morlock LL, Miller MR. J Dev Behav Pediatr. 2010;31:129-136.

STUDY

Preventable morbidity at a mature trauma center.

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

STUDY

Medication errors during medical emergencies in a large, tertiary care, academic medical center.

Gokhman R, Seybert AL, Phrampus P, Darby J, Kane-Gill SL. Resuscitation. 2012;83:482-487.

STUDY

Medication errors in the outpatient setting: classification and root cause analysis.

Friedman AL, Geoghegan SR, Sowers NM, Kulkarni S, Formica RN Jr. Arch Surg. 2007;142:278-283.

STUDY

Patient safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors.

Panesar SS, Carson-Stevens A, Salvilla SA, Patel B, Mirza SB, Mann B. Drug Healthc Patient Saf. 2013;5:57-65.

NEWSPAPER/MAGAZINE ARTICLE

Scant oversight of drug maker in fatal meningitis outbreak.

Grady D, Pollack A, Tavernise S. New York Times. October 6, 2012.

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