AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (62)

•Diagnostic Errors (71)

•Identification Errors (42)

•Discontinuities, Gaps, and Hand-Off Problems (201)

•Fatigue and Sleep Deprivation (42)

•Medication Safety (369)

•Medical Complications (243)

•Nonsurgical Procedural Complications (39)

•Surgical Complications (414)

•Transfusion Complications (9)

•Psychological and Social Complications (90)

Origin/Sponsor

•Africa (4)

•Asia (44)

•Australia and New Zealand (78)

•Central and South America (6)

•Europe (375)

•North America (1111)

Resource Types
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Study

Error Types

•Epidemiology of Errors and Adverse Events (606)

•Active Errors (274)

•Latent Errors (68)

•Near Miss (43)

Approach to Improving Safety

•Quality Improvement Strategies (336)

•Legal and Policy Approaches (47)

•Error Reporting and Analysis (428)

•Communication Improvement (454)

•Human Factors Engineering (190)

•Teamwork (238)

•Specialization of Care (127)

•Logistical Approaches (124)

•Culture of Safety (201)

•Technologic Approaches (210)

•Education and Training (430)

Clinical Areas

•Allied Health Services (6)

Target Audience

•Health Care Providers (1263)

•Health Care Executives and Administrators (1386)

•Non-Health Care Professionals (723)

•Patients (11)

Setting of Care

•Hospitals (1274)

•Psychiatric Facilities (4)

•Residential Facilities (27)

•Ambulatory Care (115)

•Outpatient Surgery (15)

•Patient Transport (15)

1 - 20 of 1619

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STUDY

Use of the Safety Attitudes Questionnaire as a measure in patient safety improvement.

Watts BV, Percarpio K, West P, Mills PD. J Patient Saf. 2010;6:206-209.

STUDY

Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training Program improves the cardiopulmonary resuscitation code process.

Percarpio KB, Harris FS, Hatfield BA, et al. Jt Comm J Qual Patient Saf. 2010;36:424-429:AP1.

STUDY

A novel method for reproducibly measuring the effects of interventions to improve emotional climate, indices of team skills and communication, and threat to patient outcome in a high-volume thoracic surgery center.

Nurok M, Lipsitz S, Satwicz P, Kelly A, Frankel A. Arch Surg. 2010;145:489-495.

STUDY

Communication failure in the operating room.

Halverson AL, Casey JT, Andersson J, et al. Surgery. 2011;49:305-310.

STUDY

Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units.

Mayer CM, Cluff L, Lin WT, et al. Jt Comm J Qual Patient Saf. 2011;37:365-374.

STUDY

Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training.

Paull DE, Mazzia LM, Izu BS, Neily J, Mills PD, Bagian JP. Am J Surg. 2009;198:675-678.

STUDY

The relationship of the emotional climate of work and threat to patient outcome in a high-volume thoracic surgery operating room team.

Nurok M, Evans LA, Lipsitz S, Satwicz P, Kelly A, Frankel A. BMJ Qual Saf. 2011;20:237-242.

STUDY

Incorrect surgical procedures within and outside of the operating room.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

STUDY

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.

STUDY

Attitudinal changes resulting from repetitive training of operating room personnel using high-fidelity simulation at the point of care.

Paige JT, Kozmenko V, Yang T, et al. Am Surg. 2009;75:584-591.

STUDY

The Oxford NOTECHS System: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre.

Mishra A, Catchpole K, McCulloch P. Qual Saf Health Care. 2009;18:104-108.

STUDY

Surgical team training: the Northwestern Memorial Hospital experience.

Halverson AL, Andersson JL, Anderson K, et al. Arch Surg. 2009;144:107-112.

STUDY

Measuring communication in the surgical ICU: better communication equals better care.

Williams M, Hevelone N, Alban RF, et al. J Am Coll Surg. 2010;210:17-22.

STUDY

A multidisciplinary team approach to retained foreign objects.

Cima RR, Kollengode A, Storsveen AS, et al. Jt Comm J Qual Patient Saf. 2009;35:123-132.

STUDY

Crew resource management improved perception of patient safety in the operating room.

Gore DC, Powell JM, Baer JG, et al. Am J Med Qual. 2010;25:60-63.

STUDY

The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases.

Wolf FA, Way LW, Stewart L. Ann Surg. 2010;252:477-485.

STUDY

Association between implementation of a medical team training program and surgical mortality.

Neily J, Mills PD, Young-Xu Y, et al. JAMA. 2010;304:1693-1700.

STUDY

Does teamwork improve performance in the operating room? A multilevel evaluation.

Weaver SJ, Rosen MA, DiazGranados D, et al. Jt Comm J Qual Patient Saf. 2010;36:133-142.

STUDY

Effect of a comprehensive surgical safety system on patient outcomes.

de Vries EN, Prins HA, Crolla RM, et al; SURPASS Collaborative Group. N Engl J Med. 2010;363:1928-1937.

STUDY

Information needs in operating room teams: what is right, what is wrong, and what is needed?

Wong HW, Forrest D, Healey A, et al. Surg Endosc. 2011;25:1913-1920.

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