AHRQ Patient Safety Network

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The Collection

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Safety Target

•Device-related Complications (11)

•Diagnostic Errors (18)

•Identification Errors (8)

•Discontinuities, Gaps, and Hand-Off Problems (38)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (70)

•Medical Complications (29)

•Nonsurgical Procedural Complications (13)

•Surgical Complications (57)

•Transfusion Complications (1)

•Psychological and Social Complications (12)

Origin/Sponsor

•Asia (4)

•Australia and New Zealand (21)

•Europe (70)

•North America (218)

Resource Types
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Review

Error Types

•Epidemiology of Errors and Adverse Events (79)

•Active Errors (47)

•Latent Errors (25)

•Near Miss (2)

Approach to Improving Safety

•Quality Improvement Strategies (57)

•Legal and Policy Approaches (20)

•Error Reporting and Analysis (83)

•Communication Improvement (81)

•Human Factors Engineering (45)

•Teamwork (34)

•Specialization of Care (15)

•Logistical Approaches (21)

•Culture of Safety (25)

•Technologic Approaches (61)

•Education and Training (59)

Clinical Areas

•Allied Health Services (1)

•Medicine (226)

•Nursing (19)

•Pharmacy (20)

Target Audience

•Health Care Providers (237)

•Health Care Executives and Administrators (255)

•Non-Health Care Professionals (139)

•Patients (4)

Setting of Care

•Hospitals (174)

•Residential Facilities (3)

•Ambulatory Care (20)

•Outpatient Surgery (3)

•Patient Transport (4)

1 - 20 of 312

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REVIEW

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.

REVIEW

Avoiding wrong site surgery: a systematic review.

DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.

REVIEW

Communication devices in the operating room.

Ruskin KJ. Curr Opin Anaesthesiol. 2006;19:655-659.

REVIEW

A systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery.

Borchard A, Schwappach DL, Barbir A, Bezzola P. Ann Surg. 2012;256:925-933.

REVIEW

The recurring problem of retained swabs and instruments.

Mahran MA, Toeima E, Morris EP. Best Pract Res Clin Obstet Gynaecol. 2013 Apr 8; [Epub ahead of print].

REVIEW

Missed injuries in trauma patients: a literature review.

Pfeifer R, Pape HC. Patient Saf Surg. 2008;2:20.

REVIEW

Enhancing communication in surgery through team training interventions: a systematic literature review.

Gillespie BM, Chaboyer W, Murray P. AORN J. 2010;92:642-657.

REVIEW

Noise in the operating room—what do we know? A review of the literature.

Hasfeldt D, Laerkner E, Birkelund R. J Perianesth Nurs. 2010;25:380-386.

REVIEW

Determining the state of knowledge for implementing the Universal Protocol recommendations: an integrative review of the literature.

Conrardy JA, Brenek B, Myers S. AORN J. 2010;92:194-207.

REVIEW

Hospital do-not-resuscitate orders: why they have failed and how to fix them.

Yuen JK, Reid MC, Fetters MD. J Gen Intern Med. 2011;26:791-797.

REVIEW

Human factors in surgery: from Three Mile Island to the operating room.

D'Addessi A, Bongiovanni L, Volpe A, Pinto F, Bassi P. Urol Int. 2009;83:249-257.

REVIEW

Monitoring for medication errors in outpatient settings.

Balkrishnan R, Foss CE, Pawaskar M, Uhas AA, Feldman SR. J Dermatolog Treat. 2009;20:229-232.

REVIEW

Year in review: medication mishaps in the elderly.

Peron EP, Marcum ZA, Boyce R, Hanlon JT, Handler SM. Am J Geriatr Pharmacother. 2011;9:1-10.

REVIEW

Minimizing surgical error by incorporating objective assessment into surgical education.

Champion HR, Meglan DA, Shair EK. J Am Coll Surg. 2008;207:284-291.

REVIEW

Preventable errors in the operating room: retained foreign bodies after surgery--part I.

Gibbs VC, Coakley FD, Reines HD. Curr Probl Surg. 2007;44:281-337.

REVIEW

Information transfer and communication in surgery: a systematic review.

Nagpal K, Vats A, Lamb B, et al. Ann Surg. 2010;252:225-239.

REVIEW

Surgical fires, a clear and present danger.

Yardley IE, Donaldson LJ. Surgeon. 2010;8:87-92.

REVIEW

A systematic review of failures in handoff communication during intrahospital transfers.

Ong MS, Coiera E. Jt Comm J Qual Patient Saf. 2011;37:274-284.

REVIEW

Detecting adverse events in dermatologic surgery.

Pinney D, Pearce DJ, Feldman SR. Dermatol Surg. 2010;36:8-14.

REVIEW

Can we make postoperative patient handovers safer? A systematic review of the literature.

Segall N, Bonifacio AS, Schroeder RA, et al; Durham VA Patient Safety Center of Inquiry. Anesth Analg. 2012;115:102-115.

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