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 (17)

•Diagnostic Errors (41)

•Identification Errors (17)

•Discontinuities, Gaps, and Hand-Off Problems (73)

•Fatigue and Sleep Deprivation (15)

•Medication Safety (297)

•Medical Complications (47)

•Nonsurgical Procedural Complications (5)

•Surgical Complications (62)

•Transfusion Complications (3)

•Psychological and Social Complications (12)

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•Asia (3)

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•Journal Article (441)

•Legislation/Regulation (2)

•Newspaper/Magazine Article (33)

•Press Release/Announcement (1)

•Web Resource (4)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (78)

•Legal and Policy Approaches (32)

•Error Reporting and Analysis (195)

•Communication Improvement (104)

•Human Factors Engineering (29)

•Teamwork (13)

•Specialization of Care (36)

•Logistical Approaches (42)

•Culture of Safety (20)

•Technologic Approaches (117)

•Education and Training (80)

Clinical Areas

•Allied Health Services (1)

•Medicine (391)

•Nursing (30)

•Pharmacy (116)

Target Audience

•Health Care Providers (381)

•Health Care Executives and Administrators (340)

•Non-Health Care Professionals (151)

•Patients (43)

Setting of Care

•Hospitals (303)

•Psychiatric Facilities (3)

•Residential Facilities (20)

•Ambulatory Care (100)

•Outpatient Surgery (8)

•Patient Transport (3)

1 - 20 of 496

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NEWSPAPER/MAGAZINE ARTICLE

Mistakes, some deadly, haunt county jails.

Carter M. Seattle Times. March 9, 2007:A1.

STUDY

Out-of-hospital medication errors: a 6-year analysis of the national poison data system.

Shah K, Barker KA. Pharmacoepidemiol Drug Saf. 2009;18:1080-1085.

STUDY

Inadequate health literacy among paid caregivers of seniors.

Lindquist LA, Jain N, Tam K, Martin GJ, Baker DW. J Gen Intern Med. 2011;26:474-479.

BOOK/REPORT

Adverse Health Events in Minnesota: Ninth Annual Public Report.

St. Paul, MN: Minnesota Department of Health; January 2013.

STUDY

Diagnostic inaccuracy of smartphone applications for melanoma detection.

Wolf JA, Moreau J, Akilov O, et al. JAMA Dermatol. 2013 Jan 16; [Epub ahead of print].

STUDY

Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients.

Brenner S, Detz A, López A, Horton C, Sarkar U. BMJ Qual Saf. 2012;21:670-675.

NEWSPAPER/MAGAZINE ARTICLE

A silent epidemic.

Boodman SG. Washington Post. February 20, 2007:HE01.

STUDY

Adverse drug events in ambulatory care.

Gandhi TK, Weingart SN, Borus J, et al. N Engl J Med. 2003;348:1556-1564.

AUDIOVISUAL PRESENTATION

Medication error death rate up 500 percent.

Spiesel S, Chadwick A. "Day to Day." National Public Radio. August 27, 2008.

STUDY

Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial.

Schnipper JL, Gandhi TK, Wald JS, et al. J Am Med Inform Assoc. 2012;19:728-734.

COMMENTARY classic

Epidemiology of medical error.

Weingart SN, Wilson RM, Gibberd RW, Harrison B. BMJ. 2000;320:774-777.

NEWSPAPER/MAGAZINE ARTICLE

Software for symptoms.

Borzo J. Wall Street Journal. May 23, 2005:R10.

STUDY

Junior doctors and patient safety: evaluating knowledge, attitudes and perception of safety climate.

Durani P, Dias J, Singh HP, Taub N. BMJ Qual Saf. 2013;22:65-71.

STUDY

Potentially inappropriate medications and adverse drug effects in elders in the ED.

Nixdorff N, Hustey FM, Brady AK, Vaji K, Leonard M, Messinger-Rapport BJ. Am J Emerg Med. 2008;26:697-700.

STUDY

Patient safety perceptions of primary care providers after implementation of an electronic medical record system.

McGuire MJ, Noronha G, Samal L, Yeh HC, Crocetti S, Kravet S. J Gen Intern Med. 2013;28:184-192.

STUDY

Exploring the role of salient distracting clinical features in the emergence of diagnostic errors and the mechanisms through which reflection counteracts mistakes.

Mamede S, Splinter TAW, van Gog T, Rikers RM, Schmidt HG. BMJ Qual Saf. 2012;21:295-300.

COMMENTARY

Automated electronic reminders to prevent miscommunication among primary medical, surgical and anaesthesia providers: a root cause analysis.

Freundlich RE, Grondin L, Tremper KK, Saran KA, Kheterpal S. BMJ Qual Saf. 2012;21:850-854.

COMMENTARY

An elusive balance — residents' work hours and the continuity of care.

Okie S. N Engl J Med. 2007;356:2665-2667.

BOOK/REPORT

Medmarx Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005.

Rockville, MD: United States Pharmacopeia; 2007.

STUDY

Reducing warfarin medication interactions: an interrupted time series evaluation.

Feldstein AC, Smith DH, Perrin N, et al. Arch Intern Med. 2006;166:1009-1015.

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