AHRQ Patient Safety Network

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The Collection

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Safety Target

•Device-related Complications (71)

•Diagnostic Errors (114)

•Identification Errors (69)

•Discontinuities, Gaps, and Hand-Off Problems (240)

•Fatigue and Sleep Deprivation (51)

•Medication Safety (614)

•Medical Complications (232)

•Nonsurgical Procedural Complications (43)

•Surgical Complications (352)

•Transfusion Complications (10)

•Psychological and Social Complications (99)

Origin/Sponsor

•Africa (5)

•Asia (63)

•Australia and New Zealand (105)

•Central and South America (6)

•Europe (451)

•North America (1359)

Resource Types
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Study

Error Types

•Epidemiology of Errors and Adverse Events (1026)

•Active Errors (383)

•Latent Errors (83)

•Near Miss (58)

Approach to Improving Safety

•Quality Improvement Strategies (394)

•Legal and Policy Approaches (62)

•Error Reporting and Analysis (622)

•Communication Improvement (455)

•Human Factors Engineering (269)

•Teamwork (218)

•Specialization of Care (121)

•Logistical Approaches (153)

•Culture of Safety (214)

•Technologic Approaches (320)

•Education and Training (457)

Clinical Areas

•Allied Health Services (7)

Target Audience

•Health Care Providers (1503)

•Health Care Executives and Administrators (1721)

•Non-Health Care Professionals (868)

•Patients (16)

Setting of Care

•Hospitals (1476)

•Psychiatric Facilities (11)

•Residential Facilities (41)

•Ambulatory Care (186)

•Outpatient Surgery (16)

•Patient Transport (22)

1 - 20 of 1992

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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

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

STUDY

Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme.

Neily J, Mills PD, Lee P, et al. Qual Saf Health Care. 2010;19:360-364.

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

Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.

Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.

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

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

Uncomfortable prescribing decisions in hospitals: the impact of teamwork.

Lewis PJ, Tully MP. J R Soc Med. 2009;102:481-488.

STUDY

Application of human error theory in case analysis of wrong procedures.

Duthie EA. J Patient Saf. 2010;6:108-114.

STUDY

Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.

Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.

STUDY

Communication failure in the operating room.

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

STUDY

Process changes to increase compliance with the Universal Protocol for bedside procedures.

Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.

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

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

Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.

Dunn EJ, Moga PJ. Arch Pathol Lab Med. 2010;134:244-255.

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

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

A multidisciplinary teamwork training program: The Triad for Optimal Patient Safety (TOPS) experience.

Sehgal NL, Fox M, Vidyarthi AR, et al; TOPS Project. J Gen Intern Med. 2008;23:2053-2057.

STUDY

Determination of health-care teamwork training competencies: a Delphi study.

Clay-Williams R, Braithwaite J. Int J Qual Health Care. 2009;21:433-440.

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.

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