The occurrence of potential patient safety events among trauma patients: are they random?

David C. Chang; Neal Handly; Fizan Abdullah; David T. Efron; Elliott R. Haut; Adil H. Haider; Peter Pronovost; Edward E. Cornwell

Study

The occurrence of potential patient safety events among trauma patients: are they random?

March 5, 2008

Chang DC, Handly N, Abdullah F, et al. Ann Surg. 2008;247(2):327-34.

View more articles from the same authors.

Using AHRQ's Patient Safety Indicators, this study discovered that events expected to be random in nature in fact occur with greater likelihood in trauma patients who are male, black, and older than 35 years.

PubMed citation

Available at

Related Resources From the Same Author(s)

A target to achieve zero preventable trauma deaths through quality improvement.

April 25, 2018

Beating the weekend trend: increased mortality in older adult traumatic brain injury (TBI) patients admitted on weekends.

August 22, 2012

Improved prophylaxis and decreased rates of preventable harm with the use of a mandatory computerized clinical decision support tool for prophylaxis for venous thromboembolism in trauma.

February 20, 2013

Undertriage of elderly trauma patients to state-designated trauma centers.

October 8, 2008

Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after 1,946,831 operations in children.

November 24, 2010

Practices to prevent venous thromboembolism: a brief review.

February 19, 2014

The CMS ruling on venous thromboembolism after total knee or hip arthroplasty: weighing risks and benefits.

March 18, 2009

State-mandated hospital infection reporting is not associated with decreased pediatric health care–associated infections.

September 9, 2015

Preventability of hospital-acquired venous thromboembolism.

August 19, 2015

Mitigating the July effect.

July 7, 2021

COVID-19: the dark side and the sunny side for patient safety.

October 14, 2020

Defining optimal length of opioid pain medication prescription after common surgical procedures.

October 18, 2017

Patient safety and quality improvement adaptation during the COVID-19 pandemic.

April 21, 2021

Agency for Healthcare Research and Quality pediatric indicators as a quality metric for surgery in children: do they predict adverse outcomes?

February 1, 2012

Diagnostic errors--The next frontier for patient safety.

March 18, 2009

Supporting the emotional well-being of health care workers during the COVID-19 pandemic.

August 5, 2020

Incidence and predictors of opioid prescription at discharge after traumatic injury.

July 12, 2017

Association of clinician diagnostic performance with machine learning–based decision support systems: a systematic review.

April 14, 2021

Conflict of interest, Dr Charles Denham and the Journal of Patient Safety.

December 3, 2014

Impact of nurse peer review on a culture of safety.

October 3, 2018

The "weekend effect" in pediatric surgery—increased mortality for children undergoing urgent surgery during the weekend.

August 6, 2014

View the world through a different lens: shadowing another provider.

October 8, 2008

The Armstrong Institute Resident/Fellow Scholars: a multispecialty curriculum to train future leaders in patient safety and quality improvement.

July 13, 2016

The need for systems integration in health care.

March 9, 2011

Physician autonomy and informed decision making: finding the balance for patient safety and quality.

January 14, 2009

Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes.

January 16, 2008

Latent risk assessment tool for health care leaders.

April 25, 2018

Are amended surgical pathology reports getting to the correct responsible care provider?

July 16, 2014

The Johns Hopkins Hospital: identifying and addressing risks and safety issues.

March 6, 2005

Setting priorities for patient safety: ethics, accountability, and public engagement.

September 2, 2009

Physician motivation: listening to what pay-for-performance programs and quality improvement collaboratives are telling us.

November 11, 2015

Association of measured quality with financial health among U.S. hospitals.

May 4, 2022

Defining and measuring patient safety.

March 6, 2005

Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations.

April 18, 2007

Incidence and types of adverse events and negligent care in Utah and Colorado.

March 27, 2005

Association of measured quality and future financial performance among hospitals performing cardiac surgery.

December 7, 2022

Rating the raters: the inconsistent quality of health care performance measurement.

March 2, 2016

A framework for operationalizing risk: a practical approach to patient safety.

May 2, 2018

When disasters strike the emergency department: a case series and narrative review.

November 10, 2021

The role of South--North partnerships in promoting shared learning and knowledge transfer.

September 6, 2017

25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank.

May 1, 2013

The impact of major intraoperative adverse events on hospital readmissions.

August 17, 2016

Tracking progress in patient safety: an elusive target.

August 16, 2006

What's the difference between a hospital and a bottling factory?

August 5, 2009

Controversy and quality improvement: lingering questions about ethics, oversight, and patient safety research.

May 28, 2008

Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center.

March 6, 2005

Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023.

October 4, 2023

A patient safety checklist for the cardiac catheterisation laboratory.

January 7, 2015

The quality of pharmacologic care for vulnerable older patients.

March 6, 2005

The objective impact of clinical peer review on hospital quality and safety.

February 16, 2011

An assessment of the impact of just culture on quality and safety in US hospitals.

May 9, 2018

An organizational learning framework for patient safety.

April 13, 2016

In pursuit of quality and safety: an 8-year study of clinical peer review best practices in US hospitals.

November 28, 2018

A longitudinal study of clinical peer review's impact on quality and safety in US hospitals.

November 27, 2013

Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit.

March 9, 2011

The "To Err Is Human Report" and the patient safety literature.

June 14, 2006

Monitoring and reducing central line-associated bloodstream infections: a national survey of state hospital associations.

June 30, 2010

Operating room briefings: working on the same page.

June 14, 2006

Learning accountability for patient outcomes.

July 21, 2010

We need leaders: the 48th Annual Rovenstine Lecture.

May 19, 2010

Enhancing physicians' use of clinical guidelines.

January 8, 2014

An interview with Peter Pronovost

November 2, 2005

Improving patient safety reporting with the common formats: common data representation for Patient Safety Organizations.

November 16, 2016

Veterans Health Administration response to the COVID-19 crisis: surveillance to action.

October 26, 2022

A practical framework for patient care teams to prospectively identify and mitigate clinical hazards.

February 11, 2009

Reasons provided by prescribers when overriding drug–drug interaction alerts.

November 28, 2007

The attributes of medical event reporting systems.

March 27, 2005

Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses.

April 13, 2016

Is there a "July phenomenon" in pediatric neurosurgery at teaching hospitals?

November 1, 2006

Standardizing patient safety event reporting between care delivered or purchased by the Veterans Health Administration (VHA).

April 10, 2024

Diffusion of surgical innovations, patient safety, and minimally invasive radical prostatectomy.

July 16, 2014

Measurement as a performance driver: the case for a national measurement system to improve patient safety.

April 26, 2017

Diagnostic errors in the pediatric and neonatal ICU: a systematic review.

March 4, 2015

Exploring organizational context and structure as predictors of medication errors and patient falls.

May 28, 2008

Developing process-support tools for patient safety: finding the balance between validity and feasibility.

October 8, 2008

Negligent care and malpractice claiming behavior in Utah and Colorado.

March 27, 2005

The evolution of patient safety procedures in an oral surgery department

December 11, 2019

Association between implementation of a medical team training program and surgical mortality.

October 20, 2010

Association between implementation of a medical team training program and surgical morbidity.

January 4, 2012

Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years?

February 26, 2014

Overview of progress on patient safety.

January 12, 2011

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

February 17, 2010

National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings.

January 16, 2013

How to use an article about quality improvement.

December 1, 2010

What can we learn about patient safety from information sources within an acute hospital: a step on the ladder of integrated risk management?

June 25, 2008

A morning briefing: setting the stage for a clinically and operationally good day.

August 10, 2005

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections.

August 25, 2010

Teamwork in healthcare: key discoveries enabling safer, high-quality care.

July 11, 2018

Using incident reporting to improve patient safety: a conceptual model.

March 28, 2007

Surgical never events in the United States.

January 9, 2013

Improving medication safety during hospital-based transitions of care.

June 17, 2015

Improving maternal safety at scale with the mentor model of collaborative improvement.

May 23, 2018

Variation in caregiver perceptions of teamwork climate in labor and delivery units.

July 5, 2006

Do hospital boards matter for better, safer, patient care?

March 8, 2017

Outcomes after out-of-hospital endotracheal intubation errors.

February 18, 2009

Balancing "no blame" with accountability in patient safety.

October 7, 2009

Rethinking rapid response teams.

September 29, 2010

Building a highway to quality health care.

September 7, 2016

"Never events" and the quest to reduce preventable harm.

June 3, 2015

A piece of my mind. From shame to guilt to love.

January 6, 2016

Related Resources

Association of hospital markup with preventable adverse events following pancreatic surgery in the United States.

February 7, 2024

Patient Safety Innovations

The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation

August 30, 2023

Factors associated with diagnostic error: an analysis of closed medical malpractice claims.

April 19, 2023

Variation in the reporting of elective surgeries and its influence on patient safety indicators.

July 6, 2022

The association of acute COVID-19 infection with Patient Safety Indicator-12 events in a multisite healthcare system.

May 25, 2022

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports.

May 18, 2022

Changes in hospital-acquired conditions and mortality associated with the hospital-acquired condition reduction program.

September 29, 2021

Identifying trigger concepts to screen emergency department visits for diagnostic errors.

December 16, 2020

Adverse events present on arrival to the emergency department: the ED as a dual safety net.

March 11, 2020

Validation of new ICD-10-based patient safety indicators for identification of in-hospital complications in surgical patients: a study of diagnostic accuracy.

September 11, 2019

Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications.

May 8, 2019

The association between complications, incidents, and patient experience: retrospective linkage of routine patient experience surveys and safety data.

March 27, 2019

Factors associated with emergency department visits and hospital admissions after invasive outpatient procedures in the Veterans Health Administration.

May 30, 2018

Vital signs: trends in emergency department visits for suspected opioid overdoses- United States, July 2016- September 2017.

March 21, 2018

Preventing mistransfusions: an evaluation of institutional knowledge and a response.

February 21, 2018

Emergency department contribution to the prescription opioid epidemic.

February 21, 2018

Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study.

January 31, 2018

Opioid abuse and poisoning: trends in inpatient and emergency department discharges.

November 1, 2017

Opioid prescribing for opioid-naive patients in emergency departments and other settings: characteristics of prescriptions and association with long-term use.

October 25, 2017

Medication errors in injured patients.

September 27, 2017

Description and yield of current quality and safety review in selected US academic emergency departments.

August 30, 2017

Incidence and predictors of opioid prescription at discharge after traumatic injury.

July 12, 2017

Emergency medical services responders' perceptions of the effect of stress and anxiety on patient safety in the out-of-hospital emergency care of children: a qualitative study.

March 22, 2017

Opioid-prescribing patterns of emergency physicians and risk of long-term use.

March 1, 2017

A patient safety dilemma: obesity in the surgical patient.

February 15, 2017

Early death after discharge from emergency departments: analysis of national US insurance claims data.

February 15, 2017

Using harm-based weights for the AHRQ Patient Safety for Selected Indicators composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health Administration hospitals?

February 1, 2017

US emergency department visits for outpatient adverse drug events, 2013–2014.

November 23, 2016

Deriving ICD-10 codes for patient safety indicators for large-scale surveillance using administrative hospital data.

October 12, 2016

Consumer rankings and health care: toward validation and transparency.

October 12, 2016

See More About The Topic

Hospitals

Emergency Medicine

Surgery

Epidemiology of Errors and Adverse Events

Error Analysis

The occurrence of potential patient safety events among trauma patients: are they random?

The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The occurrence of potential patient safety events among trauma patients: are they random?

The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site