AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (17)

•Diagnostic Errors (27)

•Identification Errors (16)

•Discontinuities, Gaps, and Hand-Off Problems (32)

•Fatigue and Sleep Deprivation (13)

•Medication Safety (61)

•Medical Complications (21)

•Nonsurgical Procedural Complications (7)

•Surgical Complications (139)

•Transfusion Complications (1)

•Psychological and Social Complications (14)

Origin/Sponsor

•Asia (3)

•Australia and New Zealand (12)

•Europe (66)

•North America (228)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (21)

•Active Errors (79)

•Latent Errors (39)

•Near Miss (6)

Approach to Improving Safety

•Quality Improvement Strategies (73)

•Legal and Policy Approaches (29)

•Error Reporting and Analysis (67)

•Communication Improvement (106)

•Human Factors Engineering (117)

•Teamwork (69)

•Specialization of Care (15)

•Logistical Approaches (26)

•Culture of Safety (49)

•Technologic Approaches (46)

•Education and Training (77)

Clinical Areas

Target Audience

•Health Care Providers (287)

•Health Care Executives and Administrators (280)

•Non-Health Care Professionals (114)

•Patients (5)

Setting of Care

•Hospitals (216)

•Ambulatory Care (14)

•Outpatient Surgery (6)

1 - 20 of 341

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COMMENTARY

A common body of care: the ethics and politics of teamwork in the operating theater are inseparable.

Bleakley A. J Med Philos. 2006;31:305-322.

COMMENTARY

Improving operating room and perioperative safety: background and specific recommendations.

Schimpff SC. Surg Innov. 2007;14:127-135.

COMMENTARY

Defining the technical skills of teamwork in surgery.

Healey AN, Undre S, Vincent CA. Qual Saf Health Care. 2006;15:231-234.

COMMENTARY

Reducing surgical complications.

Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:660-665.

COMMENTARY

How to avoid the 'seven deadly sins of surgery.'

Kirby R, Challacombe B, Dasgupta P, Fitzpatrick JM. BJU Int. 2012;109:171-173.

COMMENTARY

Right? Left? Neither!

Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.

COMMENTARY

Wise before the event.

Watts G. BMJ. 2010;340:c1378.

COMMENTARY

Inadvertent Castration.

Calland JF. AHRQ WebM&M [serial online]. January 2004.

COMMENTARY

Wrong site surgery.

Fraser SG, Adams W. Br J Ophthalmol. 2006;90:814-816.

COMMENTARY

'Balancing risk, that is my life': The politics of risk in a hospital operating theatre department.

McDonald R, Waring J, Harrison S. Health Risk Soc. 2005;7:397-411.

COMMENTARY

Instrument readiness: an important link to patient safety.

McNamara SA. AORN J. 2011;93:160-164.

COMMENTARY

Surgical team training: promoting high reliability with nontechnical skills.

Paige JT. Surg Clin North Am. 2010;90:569-581.

COMMENTARY

Engineering the system of communication for safer surgery.

Healey AN, Nagpal K, Moorthy K, Vincent CA. Cogn Tech Work. 2011;13:1-10.

COMMENTARY

Increasing patient safety and surgical team communication by using a count/time out board.

Edel EM. AORN J. 2010;92:420-424.

COMMENTARY

Secured But Not Always Safe

Jahr JS, Hosseini P. AHRQ WebM&M [serial online]. November 2006.

COMMENTARY

On O.R. Off?

Leonard M. AHRQ WebM&M [serial online]. March 2005.

COMMENTARY

Duplication of surgical site marking.

Davis JS, Karmacharya J, Schulman CI. J Patient Saf. 2012;8:151-152.

COMMENTARY

Implementing the World Health Organization surgical safety checklist: a model for future perioperative initiatives.

Styer KA, Ashley SW, Schmidt S, Zive EM, Eappen S. AORN J. 2011;94:590-598.

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.

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