AHRQ Patient Safety Network

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The Collection

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Safety Target

•Device-related Complications (40)

•Diagnostic Errors (93)

•Identification Errors (48)

•Discontinuities, Gaps, and Hand-Off Problems (130)

•Fatigue and Sleep Deprivation (50)

•Medication Safety (381)

•Medical Complications (75)

•Nonsurgical Procedural Complications (26)

•Surgical Complications (388)

•Transfusion Complications (7)

•Psychological and Social Complications (54)

Origin/Sponsor

•Africa (1)

•Asia (16)

•Australia and New Zealand (29)

•Central and South America (1)

•Europe (158)

•North America (1068)

Resource Types
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Study

Error Types

•Epidemiology of Errors and Adverse Events (536)

•Active Errors (290)

•Latent Errors (64)

•Near Miss (42)

Approach to Improving Safety

•Quality Improvement Strategies (196)

•Legal and Policy Approaches (59)

•Error Reporting and Analysis (503)

•Communication Improvement (236)

•Human Factors Engineering (210)

•Teamwork (109)

•Specialization of Care (50)

•Logistical Approaches (114)

•Culture of Safety (81)

•Technologic Approaches (194)

•Education and Training (238)

Clinical Areas

•Allied Health Services (3)

•Medicine (1027)

•Nursing (93)

•Pharmacy (109)

Target Audience

•Health Care Providers (1022)

•Health Care Executives and Administrators (957)

•Non-Health Care Professionals (437)

•Patients (12)

Setting of Care

•Hospitals (887)

•Psychiatric Facilities (2)

•Residential Facilities (15)

•Ambulatory Care (119)

•Outpatient Surgery (17)

•Patient Transport (10)

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STUDY

Time of day effects on the incidence of anesthetic adverse events.

Wright MC, Phillips-Bute B, Mark JB, et al. Qual Saf Health Care. 2006;15:258-263.

STUDY

Injury and liability associated with monitored anesthesia care: a closed claims analysis.

Bhananker SM, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB. Anesthesiology. 2006;104:228-234.

STUDY

Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.

Vermaire D, Caruso MC, Lesko A, et al. BMJ Qual Saf. 2011;20:895-902.

STUDY

Preprinted order sets as a safety intervention in pediatric sedation.

Broussard M, Bass PF 3rd, Arnold CL, McLarty JW, Bocchini JA Jr. J Pediatr. 2009;154:865-868.

STUDY

Cranshaw J, Gupta KJ, Cook TM. Anaesthesia. 2009;64:1317-1323.

STUDY

Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation.

Merry AF, Webster CS, Hannam J, et al. BMJ. 2011;343:d5543.

STUDY

An objective methodology for task analysis and workload assessment in anesthesia providers.

Weinger MB, Herndon OW, Zornow MH, Paulus MP, Gaba DM, Dallen LT. Anesthesiology. 1994;80:77-92.

STUDY

Knowledge-based errors in anesthesia: a paired, controlled trial of learning and retention.

Goldhaber-Fiebert SN, Goldhaber-Fiebert JD, Rosow CE. Can J Anaesth. 2009;56:35-45.

STUDY

Adverse respiratory events in anesthesia: a closed claims analysis.

Caplan RA, Posner KL, Ward RJ, Cheney FW. Anesthesiology. 1990;72:828-833.

STUDY

Risk factors associated with incorrect surgical counts.

Rowlands A. AORN J. 2012;96:272-284.

STUDY

Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program.

Kiran RP, Ahmed Ali U, Coffey JC, Vogel JD, Pokala N, Fazio VW. Ann Surg. 2012;256:469-475.

STUDY

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

Sexton JB, Makary MA, Tersigni AR, et al. Anesthesiology. 2006;105:877-884.

STUDY

Management of the difficult airway: a closed claims analysis.

Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Anesthesiology. 2005;103:33-39.

STUDY

A system analysis of a suboptimal surgical experience.

Lee RC, Cooke DL, Richards M. Patient Saf Surg. 2009;3:1.

STUDY

Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surgery: a review of 1200 consecutive cases.

Gordon NA, Koch ME. Arch Facial Plast Surg. 2006;8:47-53.

STUDY

Analysis of surgical errors in closed malpractice claims at 4 liability insurers.

Rogers SO Jr, Gawande AA, Kwaan M, Puopolo AL, Yoon C, Brennan TA, Studdert DM. Surgery. 2006;140:25-33.

STUDY

Surgeon age and operative mortality in the United States.

Waljee JF, Greenfield LJ, Dimick JB, Birkmeyer JD. Ann Surg. 2006;244:353-362.

STUDY

Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work.

Nemeth C, O’Connor M, Klock PA, Cook R. Org Stud. 2006;27:1011-1035.

STUDY

Liability associated with obstetric anesthesia: a closed claims analysis.

Davies JM, Posner KL, Lee LA, Cheney FW, Domino KB. Anesthesiology. 2009;110:131-139.

STUDY

Thirty-day outcomes support implementation of a surgical safety checklist.

Bliss LA, Ross-Richardson CB, Sanzari LJ, et al. J Am Coll Surg. 2012;215:766-776.

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