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 (58)

•Diagnostic Errors (94)

•Identification Errors (45)

•Discontinuities, Gaps, and Hand-Off Problems (158)

•Fatigue and Sleep Deprivation (25)

•Medication Safety (476)

•Medical Complications (156)

•Nonsurgical Procedural Complications (20)

•Surgical Complications (221)

•Transfusion Complications (9)

•Psychological and Social Complications (31)

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•Africa (1)

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Resource Types

•Audiovisual (4)

•Book/Report (33)

•Journal Article (1115)

•Legislation/Regulation (3)

•Meeting/Conference (2)

•Newspaper/Magazine Article (47)

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•Special or Theme Issue (1)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (219)

•Legal and Policy Approaches (62)

•Error Reporting and Analysis (520)

•Communication Improvement (209)

•Human Factors Engineering (114)

•Teamwork (36)

•Specialization of Care (74)

•Logistical Approaches (92)

•Culture of Safety (72)

•Technologic Approaches (211)

•Education and Training (151)

Clinical Areas

•Allied Health Services (2)

•Medicine (993)

•Nursing (88)

•Pharmacy (177)

Target Audience

•Health Care Providers (853)

•Health Care Executives and Administrators (929)

•Non-Health Care Professionals (323)

•Patients (47)

Setting of Care

•Hospitals (862)

•Psychiatric Facilities (4)

•Residential Facilities (29)

•Ambulatory Care (151)

•Outpatient Surgery (19)

•Patient Transport (13)

1 - 20 of 1214

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STUDY

A series of anesthesia-related maternal deaths in Michigan, 1985-2003.

Mhyre JM, Riesner MN, Polley LS, Naughton NN. Anesthesiology. 2007;106:1096-1104.

STUDY

Customer focused incident monitoring in anaesthesia.

Khan FA, Khimani S. Anaesthesia. 2007;62:586-590.

STUDY

Practice-based learning and improvement: a two-year experience with the reporting of morbidity and mortality cases by general surgery residents.

Falcone JL, Lee KKW, Billiar TR, Hamad GG. J Surg Educ. 2012;69:385-392.

STUDY

Intralipid medication errors in the neonatal intensive care unit.

Chuo J, Lambert G, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:104-111.

STUDY

Speaking up and sharing information improves trainee neonatal resuscitations.

Katakam LI, Trickey AW, Thomas EJ. J Patient Saf. 2012;8:202-209.

REVIEW

Fatal errors in nitrous oxide delivery.

Herff H, Paal P, von Goedecke A, Lindner KH, Keller C, Wenzel V. Anaesthesia. 2007;62:1202-1206.

STUDY

Surgeon age and operative mortality in the United States.

Waljee JF, Greenfield LJ, Dimick JB, Birkmeyer JD. Ann Surg. 2006;244:353-362.

STUDY

A facilitated survey instrument captures significantly more anesthesia events than does traditional voluntary event reporting.

Oken A, Rasmussen MD, Slagle JM, et al. Anesthesiology. 2007;107:909-922.

STUDY

A national survey of safe practice with epidural analgesia in obstetric units.

Jones R, Swales HA, Lyons GR. Anaesthesia. 2008;63:516-519.

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

The introduction of a surgical safety checklist in a tertiary referral obstetric centre.

Kearns RJ, Uppal V, Bonner J, Robertson J, Daniel M, McGrady EM. BMJ Qual Saf. 2011;20:818-822.

STUDY

The 80-hour work guidelines and resident survey perceptions of quality.

Biller CK, Antonacci AC, Pelletier S, et al. J Surg Res. 2006;135:275-281.

STUDY

Adverse events detected by clinical surveillance on an obstetric service.

Forster AJ, Fung I, Caughey S, et al. Obstet Gynecol. 2006;108:1073-1083.

BOOK/REPORT

Annual Benchmarking Report: Malpractice Risks in Surgery.

Cambridge, MA: CRICO/RMF Strategies; 2010.

STUDY

Failure to notify reportable test results: significance in medical malpractice.

Gale BD, Bissett-Siegel DP, Davidson SJ, Juran DC. J Am Coll Radiol. 2011;8:776-779.

STUDY

Preprinted order sets as a safety intervention in pediatric sedation.

Broussard M, Bass PF 3rd, Arnold CL, McLarty JW, Bocchini JA Jr. J Pediatr. 2009;154:865-868.

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

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

Overestimation of clinical diagnostic performance caused by low necropsy rates.

Shojania KG, Burton EC, McDonald KM, Goldman L. Qual Saf Health Care. 2005;14:408-413.

STUDY

Safety culture and complications after bariatric surgery.

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

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