AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (39)

•Diagnostic Errors (51)

•Identification Errors (30)

•Discontinuities, Gaps, and Hand-Off Problems (100)

•Fatigue and Sleep Deprivation (18)

•Medication Safety (171)

•Medical Complications (73)

•Nonsurgical Procedural Complications (22)

•Surgical Complications (150)

•Transfusion Complications (5)

•Psychological and Social Complications (46)

Origin/Sponsor

•Asia (4)

•Australia and New Zealand (18)

•Europe (44)

•North America (752)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (34)

•Active Errors (189)

•Latent Errors (97)

•Near Miss (17)

Approach to Improving Safety

•Quality Improvement Strategies (264)

•Legal and Policy Approaches (143)

•Error Reporting and Analysis (228)

•Communication Improvement (257)

•Human Factors Engineering (145)

•Teamwork (95)

•Specialization of Care (57)

•Logistical Approaches (59)

•Culture of Safety (179)

•Technologic Approaches (147)

•Education and Training (191)

Clinical Areas

•Allied Health Services (3)

Target Audience

•Health Care Providers (730)

•Health Care Executives and Administrators (730)

•Non-Health Care Professionals (366)

•Patients (29)

Setting of Care

•Hospitals (508)

•Psychiatric Facilities (1)

•Residential Facilities (9)

•Ambulatory Care (55)

•Outpatient Surgery (8)

•Patient Transport (5)

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COMMENTARY

Counting matters: lessons from the root cause analysis of a retained surgical item.

Agrawal A. Jt Comm J Qual Patient Saf. 2012;38:566-574.

COMMENTARY

Did We Forget Something?

Gibbs VC. AHRQ WebM&M [serial online]. September 2003.

COMMENTARY

Retained surgical items and minimally invasive surgery.

Gibbs VC. World J Surg. 2011;35:1532-1539.

COMMENTARY

Briefings, checklists, geese, and surgical safety.

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

COMMENTARY

Surgical complications: disclosing adverse events and medical errors.

Wang AS, Eisen DB. J Am Acad Dermatol. 2013;68:144-146.

COMMENTARY

Surgical count practice variability and the potential for retained surgical items.

Edel EM. AORN J. 2012;95:228-238.

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

Environmental Safety in the OR.

Linkin DR, Lautenbach E. AHRQ WebM&M [serial online]. February 2004.

COMMENTARY

The competent surgeon: individual accountability in the era of "systems" failure.

Whittemore AD. Ann Surg. 2009;250:357-362.

COMMENTARY

How long does it take to train a surgeon?

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

COMMENTARY

The Missing Suction Tip.

Thomas EJ, Moore FA. AHRQ WebM&M [serial online]. November 2003.

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

A nurse-led approach to developing and implementing a collaborative count policy.

Norton EK, Micheli AJ, Gedney J, Felkerson TM. AORN J. 2012;95:222-227.

COMMENTARY

Mark My Limb.

O'Leary DS, Jacott WE. AHRQ WebM&M [serial online]. December 2004.

COMMENTARY

Quality and safety initiatives in the future practice of surgery: meeting patient demands for enhanced professionalism.

Russell TR. Surg Today. 2009;39:739-745.

COMMENTARY

Attending work hour restrictions: is it time?

Hyman NH. Arch Surg. 2009;144:7-8.

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

Cutting out human error.

Feinmann J. BMJ. 2008;337:a2370.

COMMENTARY

Missed Appendicitis.

Adams JG. AHRQ WebM&M [serial online]. June 2003.

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