AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (45)

•Diagnostic Errors (70)

•Identification Errors (32)

•Discontinuities, Gaps, and Hand-Off Problems (114)

•Fatigue and Sleep Deprivation (22)

•Medication Safety (194)

•Medical Complications (80)

•Nonsurgical Procedural Complications (25)

•Surgical Complications (159)

•Transfusion Complications (5)

•Psychological and Social Complications (53)

Origin/Sponsor

•Asia (5)

•Australia and New Zealand (23)

•Europe (63)

•North America (831)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (42)

•Active Errors (238)

•Latent Errors (160)

•Near Miss (21)

Approach to Improving Safety

•Quality Improvement Strategies (277)

•Legal and Policy Approaches (192)

•Error Reporting and Analysis (283)

•Communication Improvement (285)

•Human Factors Engineering (168)

•Teamwork (105)

•Specialization of Care (63)

•Logistical Approaches (72)

•Culture of Safety (203)

•Technologic Approaches (163)

•Education and Training (219)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (806)

•Health Care Executives and Administrators (817)

•Non-Health Care Professionals (444)

•Patients (30)

Setting of Care

•Hospitals (561)

•Psychiatric Facilities (3)

•Residential Facilities (13)

•Ambulatory Care (73)

•Outpatient Surgery (11)

•Patient Transport (4)

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COMMENTARY

Learning from adverse events and near misses.

Greenberg CC. J Gastrointest Surg. 2008;13:3-5.

COMMENTARY

Cutting out human error.

Feinmann J. BMJ. 2008;337:a2370.

COMMENTARY

Resident duty hours in surgery for ensuring patient safety, providing optimum resident education and training, and promoting resident well-being: a response from the American College of Surgeons to the Report of the Institute of Medicine, "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety."

Britt LD, Sachdeva AK, Healy GB, Whalen TV, Blair PG; Members of the ACS Task Force on Resident Duty Hours. Surgery. 2009;146:398-409.

COMMENTARY

The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited.

Stahel PF, Mehler PS, Clarke TJ, Varnell J. Patient Saf Surg. 2009;3:14.

COMMENTARY

Disclosing harmful medical errors to patients: tackling three tough cases.

Gallagher TH, Bell SK, Smith KM, Mello MM, McDonald TB. Chest. 2009;136:897-903.

COMMENTARY classic

Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand.

Ring DC, Herndon JH, Meyer GS. N Engl J Med. 2010;363:1950-1957.

COMMENTARY

How long does it take to train a surgeon?

Purcell Jackson G, Tarpley JL. BMJ. 2009;339:b4260.

COMMENTARY

Preventable errors in organ transplantation: an emerging patient safety issue?

Ison MG, Holl JL, Ladner D. Am J Transplant. 2012;12:2307-2312.

COMMENTARY

Briefings, checklists, geese, and surgical safety.

Karl R. Ann Surg Oncol. 2010;17:8-11.

COMMENTARY

In Conversation with...Steven J. Spear, DBA, MS, MS

AHRQ WebM&M [serial online]. August 2009.

COMMENTARY

Video technology to advance safety in the operating room and perioperative environment.

Xiao Y, Schimpff S, Mackenzie C, et al. Surg Innov. 2007;14:52-61.

COMMENTARY

JCAHO's National Patient Safety Goals 2006.

Catalano K. J Perianesth Nurs. February 2006;21:6-11.

COMMENTARY

The Sorry Works! Coalition: making the case for full disclosure.

Wojcieszak D, Banja J, Houk C. Jt Comm J Qual Patient Saf. 2006;32:344-350.

COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

COMMENTARY

Checklists and guidelines: imaging techniques for visualizing what to do.

Davidoff F. JAMA. 2010;304:206-207.

COMMENTARY classic

Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.

COMMENTARY

Medicare nonpayment, hospital falls, and unintended consequences.

Inouye SK, Brown CJ, Tinetti ME. N Engl J Med. 2009;360:2390-2393.

COMMENTARY

Complications in surgery: root cause analysis and preventive measures.

Chung KC, Kotsis SV. Plast Reconstr Surg. 2012;129:1421-1427.

COMMENTARY

Patients count on it: an initiative to reduce incorrect counts and prevent retained surgical items.

Norton EK, Martin C, Micheli AJ. AORN J. 2012;1:109-121.

COMMENTARY

Shortage of perioperative drugs: implications for anesthesia practice and patient safety.

De Oliveira GS Jr, Theilken LS, McCarthy RJ. Anesth Analg. 2011;113:1429-1435.

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