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 (72)

•Diagnostic Errors (116)

•Identification Errors (57)

•Discontinuities, Gaps, and Hand-Off Problems (185)

•Fatigue and Sleep Deprivation (28)

•Medication Safety (647)

•Medical Complications (197)

•Nonsurgical Procedural Complications (25)

•Surgical Complications (220)

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•Audiovisual (4)

•Book/Report (53)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (279)

•Legal and Policy Approaches (81)

•Error Reporting and Analysis (681)

•Communication Improvement (251)

•Human Factors Engineering (141)

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•Specialization of Care (96)

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•Technologic Approaches (284)

•Education and Training (196)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (1067)

•Health Care Executives and Administrators (1242)

•Non-Health Care Professionals (464)

•Patients (59)

Setting of Care

•Hospitals (1130)

•Psychiatric Facilities (7)

•Residential Facilities (39)

•Ambulatory Care (183)

•Outpatient Surgery (24)

•Patient Transport (18)

1 - 20 of 1558

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STUDY

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

REVIEW

Epidemiology of medication-related adverse events in nursing homes.

Handler SM, Wright RM, Ruby CM, Hanlon JT. Am J Geriatr Pharmacother. 2006;4:264-272.

STUDY

The safety of hospital stroke care.

Holloway RG, Tuttle D, Baird T, Skelton WK. Neurology. 2007;68:550-555.

REVIEW

Bar code technology and medication administration error.

Young J, Slebodnik M, Sands L. J Patient Saf. 2010;6;115-120.

STUDY

The costs of adverse drug events in community hospitals.

Hug BL, Keohane C, Seger DL, Yoon C, Bates DW. Jt Comm J Qual Patient Saf. 2012;38:120-126.

STUDY

Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory.

Tsai JJ, Yeun JY, Kumar VA, Don BR. Am J Kidney Dis. 2005;46:820-829.

STUDY

Rate of occult specimen provenance complications in routine clinical practice.

Pfeifer JD, Liu J. Am J Clin Pathol. 2013;139:93-100.

STUDY

Matching identifiers in electronic health records: implications for duplicate records and patient safety.

McCoy AB, Wright A, Kahn MG, Shapiro JS, Bernstam EV, Sittig DF. BMJ Qual Saf. 2013;22:219-224.

STUDY

Antecedents of severe and nonsevere medication errors.

Chang YK, Mark BA. J Nurs Scholarsh. 2009;41:70-78.

STUDY

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

Taylor JA, Gerwin D, Morlock L, Miller MR. Inj Prev. 2011;17:388-393.

STUDY

Adverse drug event reporting in intensive care units: a survey of current practices.

Kane-Gill SL, Devlin JW. Ann Pharmacother. 2006;40:1267-73.

STUDY

Adverse drug events caused by serious medication administration errors.

Kale A, Keohane CA, Maviglia S, Gandhi TK, Poon EG. BMJ Qual Saf. 2012;21:933-938.

REVIEW

Systematic review of medication safety assessment methods.

Meyer-Massetti C, Cheng CM, Schwappach DL, et al. Am J Health Syst Pharm. 2011;68:227-240.

NEWSPAPER/MAGAZINE ARTICLE

Leveraging technical and managerial changes to improve safety.

Pronovost P, Heifetz RA. Hosp Health Netw. March 27, 2007.

STUDY

Iatrogenic events resulting in intensive care admission: frequency, cause, and disclosure to patients and institutions.

Lehmann LS, Puopolo AL, Shaykevich S, Brennan TA. Am J Med. 2005;118:409-413.

STUDY

Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review.

Sari AB, Sheldon TA, Cracknell A, Turnbull A. BMJ. 2007;334;79.

STUDY

Outcomes of care by hospitalists, general internists, and family physicians.

Lindenauer PK, Rothberg MB, Pekow PS, Kenwood C, Benjamin EM, Auerbach AD. N Engl J Med. 2007;357:2589-2600.

STUDY

Outside case review of surgical pathology for referred patients: the impact on patient care.

Swapp RE, Aubry MC, Salomão DR, Cheville JC. Arch Pathol Lab Med. 2013;137:233-240.

STUDY

Supratherapeutic dosing of acetaminophen among hospitalized patients.

Zhou L, Maviglia SM, Mahoney LM, et al. Arch Intern Med. 2012;172:1721-1728.

STUDY

An intervention to decrease catheter-related bloodstream infections in the ICU.

Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.

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