Narrow Results Clear All
- Review 1
- Study 1
- Slideset 2
- Legislation/Regulation 5
- Special or Theme Issue 1
- Glossary 1
- Toolkit 11
- Web Resource 118
- Award 2
- Meeting/Conference 5
- Press Release/Announcement 2
- Communication Improvement 31
- Culture of Safety 39
Education and Training
- Students 1
Error Reporting and Analysis
- Never Events 13
- Error Reporting 62
- Human Factors Engineering 17
- Legal and Policy Approaches 42
- Logistical Approaches 5
- Policies and Operations 8
Quality Improvement Strategies
- Benchmarking 13
- Research Directions 4
- Specialization of Care 7
- Teamwork 9
- Clinical Information Systems 16
- Transparency and Accountability 5
- Device-related Complications 9
- Diagnostic Errors 8
- Discontinuities, Gaps, and Hand-Off Problems 15
- Drug shortages 3
- Failure to rescue 1
- Fatigue and Sleep Deprivation 2
- Identification Errors 7
- Inpatient suicide 1
- Interruptions and distractions 1
- Medical Complications 32
- Medication Errors/Preventable Adverse Drug Events 22
- Nonsurgical Procedural Complications 4
- Overtreatment 3
- Psychological and Social Complications 22
- Surgical Complications 31
- Transfusion Complications 2
- Allied Health Services 1
- Internal Medicine 54
- Primary Care 14
- Surgery 20
- Nursing 5
- Pharmacy 13
- Family Members and Caregivers 5
- Health Care Executives and Administrators 253
Health Care Providers
- Nurses 4
- Physicians 20
Non-Health Care Professionals
- Educators 14
- Media 2
- Patients 25
- Africa 2
- Australia and New Zealand 6
- Europe 71
- Canada 11
United States of America
United States Federal Government
- Department of Health and Human Services (HHS) 63
- United States Federal Government 82
Search results for "Epidemiology of Errors and Adverse Events"
- Epidemiology of Errors and Adverse Events
Boston, MA: National Patient Safety Foundation; 2015.
This report provides an objective assessment of the state of the safety field 15 years after the release of the Institute of Medicine's To Err Is Human. Acknowledging that progress has been slower than anticipated, the report makes eight recommendations for achieving total system safety, including creating a common set of safety metrics that reflect meaningful outcomes, establishing and sustaining a culture of safety, centralizing oversight of patient safety at the national level, improving the safety of information technology, and supporting patients, families, and the health care workforce. The report also highlights the need for greater investment in patient safety, particularly in the outpatient and long-term care areas. Dr. Tejal Gandhi, President and CEO of the National Patient Safety Foundation (NPSF), discussed the evolving responsibilities of NPSF in a 2014 PSNet interview.
Rockville, MD: Agency for Healthcare Research and Quality; December 2015. AHRQ Publication No. 16-0009-EF.
The Partnership for Patients initiative has led efforts to reduce hospital-acquired conditions (HACs), such as health care–associated infections and other never events. Since 2010, AHRQ has been tracking rates of HACs including adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, pressure ulcers, and surgical site infections. This interim update demonstrates that HACs were reduced by 17% in 2014, indicating that the previously reported decline has been sustained. With this decrease in HACs, the analysis estimates that 87,000 fewer hospital patients died and $19.8 billion in health care costs were saved from 2011 to 2014. Although HACs persist despite incentives and strategies to eliminate them, these reductions indicate that hospitals have made substantial progress in improving safety.
2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No.16-0006-EF.
Hospital-acquired conditions (HACs), some of which are never events, have been an important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading to significant efforts to prevent these conditions. This update to a prior report from AHRQ details and confirms the declining rates in HACs between 2010 and 2013. The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years (2011–2013) than if the HAC rate had remained at the 2010 level. Consequently, the report estimates a $12 billion savings in health care costs and 50,000 fewer hospital patient deaths. These improvements coincided with nationwide efforts to reduce adverse events, such as the Partnership for Patients initiative and Medicare payment reform. The remaining burden of HACs suggests continued investment in this patient safety problem is needed.
Horsham, PA: The Institute for Safe Medication Practices; July 2015.
To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects applied expert opinion and current evidence regarding IV push medication administration to support application of best practices to facilitate safe care. To ensure the applicability and use of the recommendations in hospitals, the authors sought broader consensus and review from the field.
Powell SM, Stone RD. Peachtree City, GA: Synensis; 2015.
Engaging patients in their care is increasingly advocated as a way to improve safety. This book recommends actions for patients and families to reduce risk of error during their primary care visit, hospitalization, communications with providers, and discharge. A past AHRQ WebM&M perspective highlighted the importance of involving patients in safety.
Blumenthal D, Malphrus E, McGinnis JM, eds. Committee on Core Metrics for Better Health at Lower Cost, Institute of Medicine. Washington, DC: National Academies Press; 2015. ISBN: 9780309324939.
Measures to assess health care often add burden for overwhelmed hospital workers, and lack of consistency limits the usability of data to inform improvement. This publication reviews findings of a committee convened to discuss core measures for health care and outlines a set of 15 standardized measures to optimize performance assessment and develop data that drives progress.
Wachter R. New York, NY: McGraw-Hill; 2015. ISBN: 9780071849463.
Over the past few years, driven by $30 billion of federal incentives to doctors and hospitals, the adoption rate for electronic health records has dramatically increased, from approximately 10% in 2008 to 70% today. In essence, health care has switched from being a primarily analog to a primarily digital industry. While evidence suggests that the digitization of health care is having a positive effect on safety and quality, many challenges and unanticipated consequences have emerged. Written by a national leader in patient safety, this book chronicles some of these, including physician dissatisfaction, changing relationships among providers and between providers and patients, new kinds of medical mistakes, and problems with clinician work flow. It also highlights some of the opportunities arising from increasingly engaged patients and the entry of Silicon Valley into the health care market. Ultimately, it paints a hopeful picture of where health care information technology may take us, making the case that this positive future state will depend on both the evolution of the software and on changes in culture, training, and the organization of the work.
Hanlon C, Sheedy K, Kniffin T, Rosenthal J. Portland, ME: National Academy for State Health Policy; 2015.
State reporting systems were advocated early in the patient safety movement as a way to enable learning from errors. This analysis of 27 state-level reporting programs highlights that while adverse event reporting has become more sophisticated since the previous survey, only one new program has launched since then. The authors emphasize the value of partnership, collaboration, and transparency in the work of the participating states. An AHRQ WebM&M perspective spotlights state reporting programs as mechanisms to augment patient safety.
Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013.
Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 15-0011-EF.
This report from the Agency for Healthcare Research and Quality provides estimates on hospital-acquired conditions (HACs)—including never events and health care–associated infections—for hospitals in the United States from 2010 to 2013. These adverse events continue to decline steadily, with an estimated 9% decrease in most recent year over year comparison. In 2013, there were 121 HACs for every 1000 hospital admissions. These improvements resulted in significant cost-savings and reduced morbidity and mortality rates. The authors attribute this change to CMS payment reform and to the Partnership for Patients initiative. Although uncertainty about the cause of these improvements remains, the lower HAC rate clearly demonstrates that efforts to reduce patient safety problems in hospitalized patients are yielding results. The substantial remaining burden of HACs argues for more investment in patient safety in hospital settings.
Boston, MA: Harvard School of Public Health; December 2014.
This statewide public telephone survey in Massachusetts found that more than 20% of respondents experienced a medical error in the prior 5 years, and more than half of these incidents resulted in harm. Prior patient surveys have brought to light previously unrecognized safety problems, although discrepancies have been shown to exist between patient reports and other methods for detecting adverse events. Most respondents attributed adverse events to individual physicians and nurses rather than health systems, underscoring the challenge of conveying blame-free culture and systems approaches to the public. Diagnostic errors were the most common type of error reported. About half of patients who experienced medical errors reported the incident to a clinician, hospital, or official agency. Most patients did not look for safety or quality information in choosing a physician or hospital, and only a third of respondents view patient safety as a serious problem for the state. Importantly, prior to being given an explanation, less than half of respondents understood the term "medical error." These findings emphasize the divide between the high prevalence of safety hazards and the lack of public awareness of patient safety efforts and policy.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; February 2014. Report No. OEI-06-11-00370.
This report from the Office of the Inspector General examines the nationwide incidence of adverse events in skilled nursing facilities among the Medicare population. Approximately 22% of beneficiaries who stayed in a skilled nursing facility experienced an adverse event, and more than half were preventable. These results mirror previous studies documenting an overall poor level of safety culture in nursing homes. More than half of those who experienced harm were readmitted to the hospital. The report outlines recommendations, including raising awareness of safety concerns in this setting and instructing surveyors who inspect nursing homes to evaluate patient safety practices. These findings emphasize the importance of focusing outside acute care settings in order to advance patient safety by improving systems of care and by aligning accreditation and payment structures. A past AHRQ WebM&M interview discussed unique issues surrounding patient safety in the nursing home population.
An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.
Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.
This report analyzed the causes and rates of prescribing errors in the National Health Service and found that educational level had little impact on medication errors and that many were intercepted before reaching patients. The authors suggest that a standardized national prescription chart could help prevent errors.
MEDMARX Data Report: A Report on the Relationship of Drug Names and Medication Errors in Response to the Institute of Medicine's Call to Action (2003-2006 Findings and Trends 2002-2006).
Rockville, MD: United States Pharmacopeia; 2008.
This report provides an analysis of MEDMARX data from 870 hospitals on medication errors related to look-alike sound-alike drug names.
Harrisburg, PA: Pennsylvania Health Care Cost Containment Council; November 2006.
This report includes findings on the number and rate of infections in Pennsylvania hospitals in 2005.
The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety.
Boston, MA: Betsy Lehman Center for Patient Safety; June 2019.
The Betsy Lehman Center is a nonregulatory Massachusetts state agency that works to coordinate provider, patient, and policy maker efforts to reduce medical errors. This report describes the results of two studies conducted by the Center and includes a retrospective analysis of insurance claims associated with preventable medical errors. Investigators identified nearly 62,000 errors and calculated excess claim costs due to medical errors of more than $617 million over a 12-month period. The Center also conducted a patient survey exploring harms from medical errors. Respondents reported loss of trust and suboptimal disclosure practices around medical errors. These results collectively convey ongoing, large-scale safety gaps in health care delivery. A past PSNet perspective discussed the tragic error involving Betsy Lehman, who died due to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute.
Lives Lost, Lives Saved: An Updated Comparative Analysis of Avoidable Deaths at Hospitals Graded by The Leapfrog Group.
Austin M, Derk J. Baltimore, MD: Armstrong Institute for Patient Safety and Quality, and Johns Hopkins Medicine; May 2019.
Measures help track gaps in process and evidence of safety improvements. This white paper examines the performance of hospitals receiving Hospital Safety Grades and the relationship between high-level recognition and preventable harm. The report estimates that a substantial number of lives could have been saved if performance metrics had been met, but concludes that even high-performing hospitals exhibit areas in need of improvement.
Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2019. ISBN: 978926474260.
The overprescribing of prescription opioids heightens the likelihood of opioid dependence and harm. This report shares data from 25 countries to provide a baseline for the current crisis. The publication illustrates the complexity of the opioid epidemic and suggests that system-focused multisector strategies are required to address the problem.
Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report.
Sturrock J. Edinburgh, Scotland: The Scottish Government; May 2019. ISBN: 9781787817760.
Disrespectful and unprofessional behaviors are a common problem in health care. The report examines cultural issues at a National Health Service trust that affected the transparency needed to report disruptive behaviors and that limited conversation needed to facilitate local actions and improvement. Recommendations for the leadership, organizational, and system levels are provided to enable constructive change.
Omaha, NE: Nebraska Coalition for Patient Safety; 2019.
Patient Safety Organizations (PSOs) provide local evidence to inform learning among their members. This annual report describes a state-wide PSO's activities, summarizes breakdowns of data collected between 2008 and 2018, offers insights drawn from an analysis of nearly 1000 incident reports, and reviews root causes analyses on incidents such as patient suicide.
CHPSO: Sacramento, CA; 2019.
Patient Safety Organizations (PSOs) capture and analyze local data to inform learning among their members. This report highlights 2018 trends, activities, and outcomes of initiatives at a 10-state PSO. Sections of the report include high-level review of reported medication and perinatal events, safe table data analysis, and strategies to improve incident reporting.