AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (4)

•Diagnostic Errors (5)

•Identification Errors (7)

•Discontinuities, Gaps, and Hand-Off Problems (17)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (18)

•Medical Complications (6)

•Nonsurgical Procedural Complications (4)

•Surgical Complications (53)

•Psychological and Social Complications (11)

Origin/Sponsor

•Australia and New Zealand (5)

•Europe (24)

•North America (117)

Resource Types
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Review

Error Types

•Epidemiology of Errors and Adverse Events (22)

•Active Errors (17)

•Latent Errors (10)

Approach to Improving Safety

•Quality Improvement Strategies (21)

•Legal and Policy Approaches (12)

•Error Reporting and Analysis (20)

•Communication Improvement (42)

•Human Factors Engineering (18)

•Teamwork (19)

•Specialization of Care (8)

•Logistical Approaches (11)

•Culture of Safety (17)

•Technologic Approaches (24)

•Education and Training (29)

Clinical Areas

•Allied Health Services (1)

•Medicine (109)

•Nursing (7)

•Pharmacy (4)

Target Audience

•Health Care Providers (101)

•Health Care Executives and Administrators (123)

•Non-Health Care Professionals (68)

•Patients (1)

Setting of Care

•Hospitals (97)

•Residential Facilities (1)

•Ambulatory Care (10)

•Outpatient Surgery (2)

1 - 20 of 145

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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

Communication devices in the operating room.

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

REVIEW

Interventions for reducing wrong-site surgery and invasive procedures.

Mahar P, Wasiak J, Batty L, Fowler S, Cleland H, Gruen RL. Cochrane Database Syst Rev. 2012;9:CD009404.

REVIEW

Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries, and wrong site surgery.

Dagi TF, Berguer R, Moore S, Reines HD. Curr Probl Surg. 2007;44:352-381.

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

Improving safety in the operating room: a systematic literature review of retained surgical sponges.

Wan W, Le T, Riskin L, Macario A. Curr Opin Anaesthesiol. 2009;22:207-214.

REVIEW

Avoiding wrong site surgery: a systematic review.

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

REVIEW

Restricted duty hours for surgeons and impact on residents quality of life, education, and patient care: a literature review.

Pape H, Pfeifer R. Patient Saf Surg. 2009;3:3.

REVIEW

Error training: missing link in surgical education.

DaRosa DA, Pugh CM. Surgery. 2012;151:139-145.

REVIEW

Improving patient safety in the operating theatre and perioperative care: obstacles, interventions, and priorities for accelerating progress.

Sevdalis N, Hull L, Birnbach DJ. Br J Anaesth. 2012;109:i3-i16.

REVIEW

Detecting adverse events in dermatologic surgery.

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

REVIEW

Retrieval of iatrogenic intravascular foreign bodies.

Schechter MA, O'Brien PJ, Cox MW. J Vasc Surg. 2013;57:276-281.

REVIEW

Life after death: the aftermath of perioperative catastrophes.

Gazoni FM, Durieux ME, Wells L. Anesth Analg. 2008;107:591-600.

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.

REVIEW

Patient monitoring alarms in the ICU and in the operating room.

Schmid F, Goepfert MS, Reuter DA. Crit Care. 2013;17:216.

REVIEW

Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review.

Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Ann Intern Med. 2013;158(5 Pt 2):433-440.

REVIEW

Stress and burnout among surgeons: understanding and managing the syndrome and avoiding the adverse consequences.

Balch CM, Freischlag JA, Shanafelt TD. Arch Surg. 2009;144:371-376.

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.

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