Reducing medical errors and adverse events.

Julius Cuong Pham; Monica S. Aswani; Michael A. Rosen; HeeWon Lee; Matthew Huddle; Kristina Weeks; Peter Pronovost

Review

Reducing medical errors and adverse events.

February 8, 2012

Pham JC, Aswani MS, Rosen MA, et al. Annu Rev Med. 2012;63:447-63.

View more articles from the same authors.

This article provides an overview on numerous types of medical errors and adverse events, describing their impact, contributing factors, and strategies to address them.

PubMed citation

Available at

Related Resources From the Same Author(s)

On the CUSP: Stop BSI: evaluating the relationship between central line–associated bloodstream infection rate and patient safety climate profile.

November 12, 2014

Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii.

January 30, 2013

What to do with healthcare incident reporting systems.

January 29, 2014

Why don't we know whether care is safe?

April 10, 2013

Rapid response teams—walk, don't run.

October 11, 2006

Health system leaders' role in addressing racism: time to prioritize eliminating health care disparities.

February 10, 2021

Measurement of quality and assurance of safety in the critically ill.

April 8, 2009

Are temporary staff associated with more severe emergency department medication errors?

September 7, 2011

Using the opportunity estimator tool to improve engagement in a quality and safety intervention.

January 18, 2012

Measuring patient safety in the emergency department.

June 19, 2013

ReCASTing the RCA: an improved model for performing root cause analyses.

May 26, 2010

Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital.

June 12, 2013

Eradicating central line–associated bloodstream infections statewide: the Hawaii experience.

November 16, 2011

National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors.

June 29, 2011

A tool for the concise analysis of patient safety incidents.

January 13, 2016

The harm susceptibility model: a method to prioritise risks identified in patient safety reporting systems.

June 9, 2010

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

January 16, 2013

Major cultural-compatibility complex: considerations on cross-cultural dissemination of patient safety programmes.

February 22, 2012

Framework for patient safety research and improvement.

February 4, 2009

Statewide collaborative to reduce surgical site infections: results of the Hawaii Surgical Unit-Based Safety Program.

June 20, 2018

Comparison of intensive care unit medication errors reported to the United States' MedMarx and the United Kingdom's National Reporting and Learning System: a cross-sectional study.

May 29, 2013

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

August 25, 2010

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

February 16, 2011

Toward improving patient safety through voluntary peer-to-peer assessment.

January 25, 2012

Developing a measure of value in health care.

June 1, 2016

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

May 1, 2013

Rapid response systems as a patient safety strategy: a systematic review.

March 20, 2013

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

July 11, 2018

A systematic review of teamwork in the intensive care unit: what do we know about teamwork, team tasks, and improvement strategies?

July 23, 2014

February 17, 2016

A systematic review of behavioural marker systems in healthcare: what do we know about their attributes, validity and application?

September 10, 2014

Towards high-reliability organising in healthcare: a strategy for building organisational capacity.

June 7, 2017

Fostering transparency in outcomes, quality, safety, and costs.

October 12, 2016

Evaluation of a measurement system to assess ICU team performance.

January 23, 2019

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

June 3, 2015

Establishing a global learning community for incident-reporting systems.

November 10, 2010

The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs.

September 7, 2011

Executive/senior leader checklist to improve culture and reduce central line–associated bloodstream infections.

November 3, 2010

Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine.

May 3, 2017

Comparing measures of patient safety for inpatient care provided to veterans within and outside the VA system in New York.

February 27, 2008

Eliminating central line-associated bloodstream infections: a national patient safety imperative.

January 15, 2014

Diagnostic errors in the intensive care unit: a systematic review of autopsy studies.

August 8, 2012

Reducing health care hazards: lessons from the Commercial Aviation Safety Team.

April 15, 2009

Time for transparent standards in quality reporting by health care organizations.

August 16, 2017

Inappropriate drug use in the elderly: a nationwide register-based study.

August 29, 2007

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

March 9, 2011

Building high reliability teams: progress and some reflections on teamwork training.

May 8, 2013

Improving health care quality and patient safety through peer-to-peer assessment: demonstration project in two academic medical centers.

November 9, 2016

Family-centered multidisciplinary rounds enhance the team approach in pediatrics.

April 15, 2009

A 'Communication and Patient Safety' training programme for all healthcare staff: can it make a difference?

January 30, 2005

The safe day call: reducing silos in health care through frontline risk assessment.

September 24, 2014

Viewing health care delivery as science: challenges, benefits, and policy implications.

October 13, 2010

Misdiagnosis in the emergency department: time for a system solution.

February 8, 2023

From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system.

March 1, 2017

Simulation in the executive suite: lessons learned for building patient safety leadership.

January 6, 2016

An ethnographic study of health information technology use in three intensive care units.

August 30, 2017

National hospital ratings systems share few common scores and may generate confusion instead of clarity.

March 11, 2015

Quality improvement for patient safety: project-level versus program-level learning.

February 22, 2012

Team-training in healthcare: a narrative synthesis of the literature.

March 12, 2014

Handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture.

August 24, 2016

Cost and workforce implications of subjecting all physicians to aviation industry work-hour restrictions.

May 6, 2009

Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges.

July 21, 2010

Re-examining high reliability: actively organising for safety.

May 18, 2016

The wisdom and justice of not paying for "preventable complications."

May 14, 2008

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

Building team and technical competency for obstetric emergencies: the mobile obstetric emergencies simulator (MOES) system.

November 11, 2009

Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations.

April 25, 2007

Are surgeons and anesthesiologists lying to each other or gaming the system? A national random sample survey about "truth-telling practices" in the perioperative setting in the United States.

January 20, 2016

Awareness and use of a cognitive aid for anesthesiology.

September 19, 2007

Hospital board checklist to improve culture and reduce central line–associated bloodstream infections.

November 3, 2010

Using a logic model to design and evaluate quality and patient safety improvement programs.

July 25, 2012

Managing competing organizational priorities in clinical handover across organizational boundaries.

January 21, 2015

Nursing time devoted to medication administration in long-term care: clinical, safety, and resource implications.

March 18, 2009

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

March 2, 2016

National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths.

April 22, 2015

Can teamwork promote safety in organizations?

February 26, 2020

Preventability of hospital-acquired venous thromboembolism.

August 19, 2015

Variations in surgical outcomes associated with hospital compliance with safety practices.

February 8, 2012

A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: results of the morbidity and mortality conference improvement study, phase 1.

August 22, 2007

A Department of Medicine infrastructure for patient safety and clinical quality improvement.

December 20, 2017

A practical tool to learn from defects in patient care.

February 8, 2006

Overview of progress on patient safety.

January 12, 2011

Does teamwork improve performance in the operating room? A multilevel evaluation.

March 3, 2010

A multihospital safety improvement effort and the dissemination of new knowledge.

March 6, 2005

Markers for enhancing team cognition in complex environments: the power of team performance diagnosis.

August 1, 2007

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

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

January 6, 2016

Progress in patient safety: a glass fuller than it seems.

August 28, 2013

Measuring preventable harm: helping science keep pace with policy.

April 1, 2009

Diagnostic errors, health disparities, and artificial intelligence: a combination for health or harm.

September 1, 2021

Forum: The 100,000 Lives Campaign: a scientific and policy review [with IHI response].

November 1, 2006

Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st century.

March 1, 2006

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

April 18, 2007

Bridging the gap: a framework and strategies for integrating the quality and safety mission of teaching hospitals and graduate medical education.

June 17, 2015

Association of the use of a mandatory prescription drug monitoring program with prescribing practices for patients undergoing elective surgery.

September 5, 2018

Related Resources

Risk management and patient safety in the artificial intelligence era: a systematic review.

March 27, 2024

Strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain: a systematic review.

June 19, 2019

What quality and safety of care for patients admitted to clinically inappropriate wards: a systematic review.

May 8, 2019

Impact of fatigue and insufficient sleep on physician and patient outcomes: a systematic review.

October 3, 2018

Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies.

September 5, 2018

Preventable adverse drug events among inpatients: a systematic review.

August 29, 2018

The scope of drug-related problems in the home care setting.

July 25, 2018

"Doctor Jazz": lessons that medical professionals can learn from jazz musicians.

June 6, 2018

Hospital admissions associated with medication non-adherence: a systematic review of prospective observational studies.

May 23, 2018

Realist synthesis of intentional rounding in hospital wards: exploring the evidence of what works, for whom, in what circumstances and why.

May 16, 2018

Evidence review conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: focus on anesthesiology for colorectal surgery.

May 9, 2018

Diagnostic reasoning and cognitive biases of nurse practitioners.

April 25, 2018

Chemotherapy medication errors.

April 11, 2018

Pain states, the opioid epidemic, and the role of radiologists.

April 4, 2018

2017 update on pediatric medical overuse: a review.

April 4, 2018

Drug shortages: effect on parenteral nutrition therapy.

March 21, 2018

Diagnostic error in stroke — reasons and proposed solutions.

March 7, 2018

Diagnosing crime and diagnosing disease—part 1 and part 2.

February 28, 2018

Safe care for pediatric patients: a scoping review across multiple health care settings.

February 28, 2018

Symptom–Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data.

February 21, 2018

The effect of facility characteristics on patient safety, patient experience, and service availability for procedures in non–hospital-affiliated outpatient settings: a systematic review.

February 21, 2018

Suffering in silence: medical error and its impact on health care providers.

February 14, 2018

Technological distractions—part 1 and part 2.

February 14, 2018

Medication errors involving nursing students: a systematic review.

February 7, 2018

Strategies to reduce patient harm from infusion-associated medication errors: a scoping review.

January 31, 2018

Systematic evidence review of rates and burden of harm of intravenous admixture drug preparation errors in healthcare settings.

January 24, 2018

Nurses' clinical reasoning practices that support safe medication administration: an integrative review of the literature.

January 10, 2018

Interventions for the reduction of prescribed opioid use in chronic non-cancer pain.

December 6, 2017

Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action.

December 6, 2017

The impact of adverse events on clinicians: what's in a name?

November 22, 2017

See More About The Topic

Hospitals

Medicine

Error Analysis

Reducing medical errors and adverse events.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Reducing medical errors and adverse events.

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