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 (70)

•Diagnostic Errors (110)

•Identification Errors (51)

•Discontinuities, Gaps, and Hand-Off Problems (161)

•Fatigue and Sleep Deprivation (26)

•Medication Safety (560)

•Medical Complications (192)

•Nonsurgical Procedural Complications (24)

•Surgical Complications (201)

•Transfusion Complications (11)

•Psychological and Social Complications (28)

Origin/Sponsor

•Africa (1)

•Asia (28)

•Australia and New Zealand (41)

•Central and South America (6)

•Europe (223)

•North America (1055)

Resource Types

•Audiovisual (4)

•Book/Report (35)

•Journal Article (1247)

•Legislation/Regulation (3)

•Meeting/Conference (2)

•Newspaper/Magazine Article (54)

•Press Release/Announcement (3)

•Special or Theme Issue (1)

•Tools/Toolkit (1)

•Web Resource (7)

Error Types
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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (260)

•Legal and Policy Approaches (66)

•Error Reporting and Analysis (548)

•Communication Improvement (217)

•Human Factors Engineering (124)

•Teamwork (47)

•Specialization of Care (90)

•Logistical Approaches (98)

•Culture of Safety (104)

•Technologic Approaches (249)

•Education and Training (177)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (936)

•Health Care Executives and Administrators (1096)

•Non-Health Care Professionals (403)

•Patients (48)

Setting of Care

•Hospitals (983)

•Psychiatric Facilities (5)

•Residential Facilities (31)

•Ambulatory Care (160)

•Outpatient Surgery (17)

•Patient Transport (16)

1 - 20 of 1357

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STUDY

Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital.

Riley W, Davis S, Miller K, Hansen H, Sainfort F, Sweet R. Jt Comm J Qual Patient Saf. 2011;37:357-364.

STUDY

Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units.

Mayer CM, Cluff L, Lin WT, et al. Jt Comm J Qual Patient Saf. 2011;37:365-374.

STUDY

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.

STUDY

Speaking up and sharing information improves trainee neonatal resuscitations.

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

STUDY

Communication failure in the operating room.

Halverson AL, Casey JT, Andersson J, et al. Surgery. 2011;49:305-310.

STUDY

Teamwork behaviours and errors during neonatal resuscitation.

Williams AL, Lasky RE, Dannemiller JL, Andrei AM, Thomas EJ. Qual Saf Health Care. 2010;19:60-64.

STUDY

Implementing peer evaluation of handoffs: associations with experience and workload.

Arora VM, Greenstein EA, Woodruff JN, Staisiunas PG, Farnan JM. J Hosp Med. 2013;8:132-136.

STUDY

An inpatient fall prevention initiative in a tertiary care hospital.

Weinberg J, Proske D, Szerszen A, et al. Jt Comm J Qual Patient Saf. 2011;37:317-325.

STUDY

Complications and death at the start of the new academic year: is there a July phenomenon?

Inaba K, Recinos G, Teixeira PGR, et al. J Trauma. 2010;68:19-22.

STUDY

Eradicating medical student mistreatment: a longitudinal study of one institution's efforts.

Fried JM, Vermillion M, Parker NH, Uijtdehaage S. Acad Med. 2012;87:1191-1198.

BOOK/REPORT classic

Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. Updated edition.

Wachter R, Shojania K. New York, NY: Rugged Land; 2005. ISBN: 1590710738.

STUDY

Comprehensive stroke centers overcome the weekend versus weekday gap in stroke treatment and mortality.

McKinney JS, Deng Y, Kasner SE, Kostis JB; Myocardial Infarction Data Acquisition System (MIDAS 15) Study Group. Stroke. 2011;42:2403-2409.

STUDY

Medication error identification rates by pharmacy, medical, and nursing students.

Warholak TL, Queiruga C, Roush R, Phan H. Am J Pharm Educ. 2011;75:24.

STUDY

Postdischarge adverse events for 1-day hospital admissions in older adults admitted from the emergency department.

Pines JM, Mongelluzzo J, Hilton JA, et al. Ann Emerg Med. 2010;56:253-257.

REVIEW

Interventions to improve teamwork and communications among healthcare staff.

McCulloch P, Rathbone J, Catchpole K. Br J Surg. 2011;98:469-479.

STUDY

Measuring communication in the surgical ICU: better communication equals better care.

Williams M, Hevelone N, Alban RF, et al. J Am Coll Surg. 2010;210:17-22.

REVIEW

Systematic review of safety checklists for use by medical care teams in acute hospital settings—limited evidence of effectiveness.

Ko HCH, Turner TJ, Finnigan MA. BMC Health Serv Res. 2011;11:211.

STUDY

Are the Agency for Healthcare Research and Quality obstetric trauma indicators valid measures of hospital safety?

Grobman WA, Feinglass J, Murthy S. Am J Obstet Gynecol. 2006;195:868-874.

STUDY

Reducing inappropriate diagnostic practice through education and decision support.

Bairstow PJ, Persaud J, Mendelson R, Nguyen L. Int J Qual Health Care. 2010;22:194-200.

STUDY

A trigger tool fails to identify serious errors and adverse events in pediatric otolaryngology.

Lander L, Roberson DW, Plummer KM, Forbes PW, Healy GB, Shah RK. Otolaryngol Head Neck Surg. 2010;143:480-486.

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