AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (5)

•Diagnostic Errors (12)

•Identification Errors (17)

•Discontinuities, Gaps, and Hand-Off Problems (13)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (14)

•Medical Complications (10)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (111)

•Transfusion Complications (2)

•Psychological and Social Complications (10)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (5)

•Europe (16)

•North America (107)

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Commentary

Error Types

•Epidemiology of Errors and Adverse Events (23)

•Active Errors (50)

•Latent Errors (25)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (39)

•Legal and Policy Approaches (11)

•Error Reporting and Analysis (32)

•Communication Improvement (61)

•Human Factors Engineering (43)

•Teamwork (26)

•Specialization of Care (5)

•Logistical Approaches (11)

•Culture of Safety (17)

•Technologic Approaches (23)

•Education and Training (39)

Clinical Areas

•Medicine (147)

•Nursing (23)

•Pharmacy (5)

Target Audience

•Health Care Providers (144)

•Health Care Executives and Administrators (107)

•Non-Health Care Professionals (44)

•Patients (1)

Setting of Care

•Hospitals (132)

•Ambulatory Care (3)

•Outpatient Surgery (4)

1 - 20 of 155

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COMMENTARY

The lost sponge: patient safety in the operating room.

Grant-Orser A, Davies P, Singh SS. CMAJ. 2012;184:1275-1278.

COMMENTARY

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

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

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

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

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

COMMENTARY

Surgical site verification: A through Z.

Dunn D. J Perianesth Nurs. 2006;21:317-328.

COMMENTARY

Surgical complications: disclosing adverse events and medical errors.

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

COMMENTARY

Verbal medication orders in the OR.

Hendrickson T. AORN J. 2007;86:626-629.

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

Wrong site surgery.

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

COMMENTARY

The Other Side.

Vincent C. AHRQ WebM&M [serial online]. October 2003.

COMMENTARY

Attending work hour restrictions: is it time?

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

COMMENTARY

Clinical care checklists: salvations or frustrations?

Jones JW, McCullough LB. J Vasc Surg. 2011;53:1429-1430.

COMMENTARY

The Inside of a Time Out

Feldman DL. AHRQ WebM&M [serial online]. May 2008.

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

Blind Spot

Lee LA. AHRQ WebM&M [serial online]. June 2005.

COMMENTARY

Mark My Limb.

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

COMMENTARY

Defining the technical skills of teamwork in surgery.

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

COMMENTARY

Quality and safety in surgical care.

Polk HC Jr, Birkmeyer J, Hunt DR, Jones RS, Whittemore AD, Barraclough B. Ann Surg. 2006;243:439-448.

COMMENTARY

The nature of surgical error: a cautionary tale and a call to reason.

Satava RM. Surg Endosc. 2005;19:1014-1016.

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