Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010.

A. N. Thomas; R. J. Taylor

Study

Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010.

May 2, 2012

Thomas AN, Taylor RJ. Anaesthesia. 2012;67(7):706-13.

View more articles from the same authors.

Pressure ulcers were the most common voluntarily reported patient safety issue in intensive care units in this study from 12 hospital trusts in the United Kingdom.

PubMed citation

Available at

Related Resources From the Same Author(s)

Review of patient safety incidents submitted from critical care units in England & Wales to the UK National Patient Safety Agency.

December 2, 2009

Evaluation of an anonymous system to report medical errors in pediatric inpatients.

August 22, 2007

Patient safety incidents associated with airway devices in critical care: a review of reports to the UK National Patient Safety Agency.

February 18, 2009

July 16, 2008

The impact of electronic communication of medication discontinuation (CancelRx) on medication safety: a pilot study.

October 5, 2022

An educational and audit tool to reduce prescribing error in intensive care.

October 29, 2008

Impact of reduction in working hours for doctors in training on postgraduate medical education and patients' outcomes: systematic review.

April 6, 2011

Electronic trigger-based intervention to reduce delays in diagnostic evaluation for cancer: a cluster randomized controlled trial.

September 9, 2015

Framework for analysing risk and safety in clinical medicine.

July 17, 2013

Framework for analysing risk and safety in clinical medicine.

July 17, 2013

Teamwork behaviours and errors during neonatal resuscitation.

March 24, 2010

The cost of pneumonia after acute stroke.

June 13, 2007

Reframing and addressing horizontal violence as a workplace quality improvement concern.

August 22, 2018

Trends and patterns in reporting of patient safety situations in transplantation.

February 10, 2016

Simulation as a tool to improve the safety of pre-hospital anaesthesia—a pilot study.

September 23, 2009

Diagnostic errors in pediatric radiology.

March 30, 2011

Triangulating case-finding tools for patient safety surveillance: a cross-sectional case study of puncture/laceration.

February 29, 2012

Time to listen: a review of methods to solicit patient reports of adverse events.

April 14, 2010

Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system.

May 4, 2022

Opportunities to enhance laboratory professionals' role on the diagnostic team.

November 16, 2016

Electronic health record-based triggers to detect potential delays in cancer diagnosis.

August 28, 2013

Diagnostic reasoning and cognitive biases of nurse practitioners.

April 25, 2018

Research to improve diagnosis: time to study the real world.

January 26, 2022

Safety and communication in the operating room: a safety questionnaire after the implementation of a blood-borne pathogen exposure checkpoint in the surgical safety checklist preprocedure time-out.

September 25, 2019

Patient safety systems in the primary health care of diabetes—a story of missed opportunities?

November 17, 2010

Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial.

June 20, 2007

Oral outpatient chemotherapy medication errors in children with acute lymphoblastic leukemia.

August 23, 2006

CT for suspected appendicitis in children: an analysis of diagnostic errors.

March 1, 2006

Electronic health records and adverse drug events after patient transfer.

December 8, 2010

National surveillance of emergency department visits for outpatient adverse drug events.

October 18, 2006

Wrong-site surgery in Pennsylvania during 2015–2019: a study of variables associated with 368 events from 178 facilities.

January 20, 2021

Diagnostic errors with inserted tubes, lines and catheters in children.

December 5, 2012

Incidence and types of preventable adverse events in elderly patients: population based review of medical records.

March 27, 2005

Do nurse and patient injuries share common antecedents? An analysis of associations with safety climate and working conditions.

February 8, 2012

Negligent care and malpractice claiming behavior in Utah and Colorado.

March 27, 2005

Measuring safety culture in the ambulatory setting: The Safety Attitudes Questionnaire—Ambulatory Version.

March 21, 2007

Do medical inpatients who report poor service quality experience more adverse events and medical errors?

February 13, 2008

Completeness of serious adverse drug event reports received by the US Food and Drug Administration in 2014.

April 6, 2016

Improving ambulatory prescribing safety with a handheld decision support system: a randomized controlled trial.

April 26, 2006

Serious adverse drug events reported to the Food and Drug Administration, 1998-2005.

September 19, 2007

The SAGES FUSE program: bridging a patient safety gap.

October 22, 2014

Changes in the diagnostic process during 40 years of clinicopathologic conferences.

March 27, 2005

Ethics, oversight and quality improvement initiatives.

August 25, 2010

National surveillance of emergency department visits for outpatient adverse drug events in children and adolescents.

March 5, 2008

Charter on Physician Well-being.

April 11, 2018

Pharmacovigilance using clinical notes.

May 1, 2013

Improving teamwork on general medical units: when teams do not work face-to-face.

October 3, 2012

Ambulance stretcher adverse events.

June 17, 2009

Developing an action plan for patient radiation safety in adult cardiovascular medicine.

April 11, 2012

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

April 26, 2017

Development and validation of electronic health record–based triggers to detect delays in follow-up of abnormal lung imaging findings.

May 27, 2015

Using four-phased unit-based patient safety walkrounds to uncover correctable system flaws.

August 21, 2013

Second victims need emotional support after adverse events: even in a just safety culture.

April 3, 2019

Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients.

July 10, 2019

Quality and safety initiatives in the future practice of surgery: meeting patient demands for enhanced professionalism.

October 21, 2009

Discontinuation of outpatient medications: implications for electronic messaging to pharmacies using CancelRx.

December 7, 2022

Bending the patient safety curve: how much can AI help?

February 1, 2023

Understanding diagnostic errors in medicine: a lesson from aviation.

June 21, 2006

Driving improvement in patient care: lessons from Toyota.

March 6, 2005

The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II.

March 27, 2005

Computer visualisation of patient safety in primary care: a systems approach adapted from management science and engineering.

July 20, 2005

Hospital medication errors: a cross sectional study.

December 23, 2020

Type 1 diabetes defined by severe insulin deficiency occurs after 30 years of age and is commonly treated as type 2 diabetes.

May 22, 2019

Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about.

October 21, 2015

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

February 27, 2008

Applied use of safety event occurrence control charts of harm and non-harm events: a case study.

July 20, 2016

Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project.

August 18, 2010

Perspectives in quality: designing the WHO Surgical Safety Checklist.

September 1, 2010

Types and origins of diagnostic errors in primary care settings.

March 6, 2013

The quality, safety and content of telephone and face-to-face consultations: a comparative study.

June 2, 2010

Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers.

May 9, 2018

Safety skills for clinicians: an essential component of patient safety.

August 20, 2008

Medication safety at the interface: evaluating risks associated with discharge prescriptions from mental health hospitals.

January 20, 2016

Decreasing paediatric prescribing errors in a district general hospital.

April 23, 2008

Outcomes of daytime procedures performed by attending surgeons after night work.

September 2, 2015

Creating a safety culture at the Children's and Women's Health Centre of British Columbia.

February 7, 2007

Accidental deaths, saved lives, and improved quality.

October 5, 2005

Association of open communication and the emotional and behavioural impact of medical error on patients and families: state-wide cross-sectional survey.

February 12, 2020

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

March 27, 2005

Operationalizing occupational fatigue in pharmacists: an exploratory factor analysis.

November 18, 2020

Pediatric radiology malpractice claims—characteristics and comparison to adult radiology claims.

July 12, 2017

Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: multiple interrupted time series study.

January 11, 2023

Potentially inappropriate opioid prescribing, overdose, and mortality in Massachusetts, 2011–2015.

October 3, 2018

Mortality rate after nonelective hospital admission.

June 1, 2011

Safe use of electronic health records and health information technology systems: trust but verify.

December 18, 2013

Effectiveness of a computerized system for intravenous heparin administration: using information technology to improve patient care and patient safety.

May 11, 2005

September 19, 2012

Understanding the "Swiss cheese model" and its application to patient safety.

July 21, 2021

Geometric probability distribution for modeling of error risk during prescription dispensing.

June 14, 2006

Unintended errors with EHR-based result management: a case series.

February 3, 2010

Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic error.

October 5, 2016

Citation classics in patient safety research: an invitation to contribute to an online bibliography.

November 22, 2006

Role of intraoperative cholangiography in avoiding bile duct injury.

April 18, 2007

Patient involvement in patient safety: how willing are patients to participate?

March 2, 2011

Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems.

March 8, 2006

A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life.

February 2, 2011

Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit.

January 16, 2008

Incidence of adverse drug events and potential adverse drug events: implications for prevention.

March 27, 2005

The non-technical skills used by anaesthetic technicians in critical incidents reported to the Australian Incident Monitoring System between 2002 and 2008.

September 9, 2015

The harms of promoting 'Zero Harm'.

February 19, 2020

Related Resources

Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study.

June 7, 2023

Increased mortality and costs associated with adverse events in intensive care unit patients.

April 6, 2022

Problems in care and avoidability of death after discharge from intensive care: a multi-centre retrospective case record review study.

February 10, 2021

Exploring the human factors of prescribing errors in paediatric intensive care units.

March 27, 2019

Learning from excellence in healthcare: a new approach to incident reporting.

October 19, 2016

Factors associated with post-intensive care unit adverse events: a clinical validation study.

October 29, 2014

Nighttime cross-coverage is associated with decreased intensive care unit mortality. A single-center study.

September 3, 2014

Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout.

June 4, 2014

Risks in the implementation and use of smart pumps in a pediatric intensive care unit: application of the failure mode and effects analysis.

May 21, 2014

An observational study: associations between nurse-reported hospital characteristics and estimated 30-day survival probabilities.

May 21, 2014

Variability in the measurement of hospital-wide mortality rates.

March 19, 2014

Failure events in transition of care for surgical patients.

March 5, 2014

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

February 26, 2014

Outcome of adverse events and medical errors in the intensive care unit: a systematic review and meta-analysis.

February 12, 2014

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

January 15, 2014

The Orthopaedic Error Index: development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach.

December 18, 2013

Impact of contact isolation for multidrug-resistant organisms on the occurrence of medical errors and adverse events.

October 23, 2013

Prescribing errors on admission to hospital and their potential impact: a mixed-methods study.

October 16, 2013

Improving quality and safety of care using "technovigilance": an ethnographic case study of secondary use of data from an electronic prescribing and decision support system.

October 16, 2013

Is hand hygiene before putting on nonsterile gloves in the intensive care unit a waste of health care worker time? A randomized controlled trial.

September 4, 2013

The impact of rapid response team on outcome of patients transferred from the ward to the ICU: a single-center study.

August 28, 2013

Explaining Matching Michigan: an ethnographic study of a patient safety program.

August 21, 2013

Impact of organizational culture on preventability assessment of selected adverse events in the ICU: evaluation of morbidity and mortality conferences.

June 19, 2013

A systematic review of strategies for reporting of neonatal hospital–acquired bloodstream infections.

May 29, 2013

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.

May 8, 2013

Understanding factors that impact on health care professionals' risk perceptions and responses toward Clostridium difficile and methicillin-resistant Staphylococcus aureus: a structured literature review.

April 10, 2013

Adverse drug events in a paediatric intensive care unit: a prospective cohort.

March 6, 2013

The effects of computerized provider order entry implementation on communication in intensive care units.

February 20, 2013

ICU admittance by a rapid response team versus conventional admittance, characteristics, and outcome.

February 6, 2013

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

January 30, 2013

See More About The Topic

Intensive Care Units

Risk Managers

Quality and Safety Professionals

Critical Care

General Internal Medicine

Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010.

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