AHRQ Patient Safety Network

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The Collection > Epidemiology of Errors and Adverse Events

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PATIENT SAFETY PRIMERS
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Adverse Events after Hospital Discharge

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Safety Target

•Device-related Complications (73)

•Diagnostic Errors (105)

•Identification Errors (51)

•Discontinuities, Gaps, and Hand-Off Problems (170)

•Fatigue and Sleep Deprivation (27)

•Medication Safety (588)

•Medical Complications (197)

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•Journal Article (1297)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (263)

•Legal and Policy Approaches (67)

•Error Reporting and Analysis (578)

•Communication Improvement (221)

•Human Factors Engineering (129)

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•Allied Health Services (3)

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•Medicine (1136)

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Target Audience

•Health Care Providers (977)

•Health Care Executives and Administrators (1149)

•Non-Health Care Professionals (408)

•Patients (48)

Setting of Care

•Hospitals (1018)

•Psychiatric Facilities (5)

•Residential Facilities (37)

•Ambulatory Care (165)

•Outpatient Surgery (21)

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1 - 20 of 1410

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STUDY

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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.

STUDY

Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates.

Lin MY, Hota B, Khan YM, et al; CDC Prevention Epicenter Program. JAMA. 2010;304:2035-2041.

STUDY

Statewide NICU central-line–associated bloodstream infection rates decline after bundles and checklists.

Schulman J, Stricof R, Stevens TP, et al; New York State Regional Perinatal Care Centers. Pediatrics. 2011;127:436-444.

STUDY

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

Sawyer M, Weeks K, Goeschel CA, et al. Crit Care Med. 2010;38(suppl 8):S292-S298.

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

Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units.

Fuchs MA, Sexton DJ, Thornlow DK, Champagne MT. J Nurs Care Qual. 2011;26:101-109.

STUDY

Trends in central line–associated bloodstream infections in a trauma-surgical intensive care unit.

Ong A, Dysert K, Herbert C, et al. Arch Surg. 2011;146:302-307.

STUDY

Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations.

Angus DC, Shorr AF, White A, Dremsizov TT, Schmitz RJ, Kelley MA, on behalf of the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Crit Care Med. 2006;34:1016-1024.

STUDY

Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans.

Vigorito MC, McNicoll L, Adams L, Sexton B. Jt Comm J Qual Patient Saf. 2011;37:509-514.

STUDY

Toward learning from patient safety reporting systems.

Pronovost PJ, Thompson DA, Holzmueller CG, et al. J Crit Care. 2006;21:305-315.

STUDY

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

Lin DM, Weeks K, Holzmueller CG, Pronovost PJ, Pham JC. Jt Comm J Qual Patient Saf. 2013;39:51-60.

STUDY

A multicenter, phased, cluster-randomized controlled trial to reduce central line–associated bloodstream infections in intensive care units.

Marsteller JA, Sexton JB, Hsu YJ, et al. Crit Care Med. 2012;40:2933-2939.

STUDY

The ability of intensive care units to maintain zero central line–associated bloodstream infections.

Lipitz-Snyderman A, Needham DM, Colantuoni E, et al. Arch Intern Med. 2011;171:856-858.

STUDY

A comparison of voluntarily reported medication errors in intensive care and general care units.

Kane-Gill SL, Kowiatek JG, Weber RJ. Qual Saf Health Care. 2010;19:55-59.

PRESS RELEASE/ANNOUNCEMENT classic

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AHRQ Patient Safety Project Reduces Bloodstream Infections by 40 Percent.

Rockville, MD: Agency for Healthcare Research and Quality; September 10, 2012.

STUDY

Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: business case for quality improvement.

Nowak JE, Brilli RJ, Lake MR, et al. Pediatr Crit Care Med. 2010;11:579-587.

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.

PRESS RELEASE/ANNOUNCEMENT

Serious medication errors from intravenous administration of nimodipine oral capsules.

MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; August 2, 2010.

STUDY

Discontinuity of chronic medications in patients discharged from the intensive care unit.

Bell CM, Rahimi-Darabad P, Orner AI. J Gen Intern Med. 2006;21:937-941.

STUDY

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

Latif A, Rawat N, Pustavoitau A, Pronovost PJ, Pham JC. Crit Care Med. 2013;41:389-398.

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