AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (21)

•Diagnostic Errors (35)

•Identification Errors (30)

•Discontinuities, Gaps, and Hand-Off Problems (77)

•Fatigue and Sleep Deprivation (35)

•Medication Safety (115)

•Medical Complications (45)

•Nonsurgical Procedural Complications (7)

•Surgical Complications (338)

•Transfusion Complications (3)

•Psychological and Social Complications (32)

Origin/Sponsor

•Asia (11)

•Australia and New Zealand (20)

•Europe (157)

•North America (505)

Resource Types
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Study

Error Types

•Epidemiology of Errors and Adverse Events (257)

•Active Errors (130)

•Latent Errors (34)

•Near Miss (18)

Approach to Improving Safety

•Quality Improvement Strategies (123)

•Legal and Policy Approaches (20)

•Error Reporting and Analysis (215)

•Communication Improvement (156)

•Human Factors Engineering (118)

•Teamwork (96)

•Specialization of Care (28)

•Logistical Approaches (51)

•Culture of Safety (63)

•Technologic Approaches (82)

•Education and Training (159)

Clinical Areas

•Medicine (627)

•Nursing (43)

•Pharmacy (23)

Target Audience

•Health Care Providers (572)

•Health Care Executives and Administrators (610)

•Non-Health Care Professionals (251)

•Patients (2)

Setting of Care

•Hospitals (579)

•Psychiatric Facilities (1)

•Residential Facilities (3)

•Ambulatory Care (22)

•Outpatient Surgery (11)

•Patient Transport (2)

1 - 20 of 700

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STUDY

Analysis of errors enacted by surgical trainees during skills training courses.

Tang B, Hanna GB, Cuschieri A. Surgery. 2005;138:14-20.

STUDY

"First, do no harm": balancing competing priorities in surgical practice.

Leung A, Luu S, Regehr G, Murnaghan ML, Gallinger S, Moulton CA. Acad Med. 2012;87:1368-1374.

STUDY

Failures in communication and information transfer across the surgical care pathway: interview study.

Nagpal K, Arora S, Vats A, et al. BMJ Qual Saf. 2012;21:843-849.

STUDY

Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.

Espin S, Levinson W, Regehr G, Baker GR, Lingard L. Surgery. 2006;139:6-14.

STUDY

Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.

Hu YY, Arriaga AF, Roth EM, et al. Ann Surg. 2012;256:203-210.

STUDY

Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR.

Lingard L, Espin S, Rubin B, et al. Qual Saf Health Care. 2005;14:340-346.

STUDY

Realistic distractions and interruptions that impair simulated surgical performance by novice surgeons.

Feuerbacher RL, Funk KH, Spight DH, Diggs BS, Hunter JG. Arch Surg. 2012;147:1026-1030.

STUDY

Methodology and bias in assessing compliance with a surgical safety checklist.

Poon SJ, Zuckerman SL, Mainthia R, et al. Jt Comm J Qual Patient Saf. 2013;39:77-82.

STUDY

Factors compromising safety in surgery: stressful events in the operating room.

Arora S, Hull L, Sevdalis N, et al. Am J Surg. 2010;199:60-65.

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

Risk factors associated with incorrect surgical counts.

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

STUDY

Perioperative patient safety: correct patient, correct surgery, correct side--a multifaceted, cross-organizational, interventional study.

Zohar E, Noga Y, Davidson E, Kantor M, Fredman B. Anesth Analg. 2007;105:443-447.

STUDY

Surgical specimen identification errors: a new measure of quality in surgical care.

Makary MA, Epstein J, Pronovost PJ, Millman EA, Hartmann EC, Freischlag JA. Surgery. 2007;141:450-455.

STUDY

Observational assessment of surgical teamwork: a feasibility study.

Undre S, Healey AN, Darzi A, Vincent CA. World J Surg. 2006;30:1774-1783.

STUDY

Communication practices on 4 Harvard surgical services: a surgical safety collaborative.

ElBardissi AW, Regenbogen SE, Greenberg CC, et al. Ann Surg. 2009;250:861-865.

STUDY

'Skating on thin ice?' Consultant surgeon's contemporary experience of adverse surgical events.

Skevington SM, Langdon JE, Giddins G. Psychol Health Med. 2012;17:1-16.

STUDY

Waking up the next morning: surgeons' emotional reactions to adverse events.

Luu S, Patel P, St-Martin L, et al. Med Educ. 2012;46:1179-1188.

STUDY

Surgical site signing and "time out": issues of compliance or complacence.

Johnston G, Ekert L, Pally E. J Bone Joint Surg Am. 2009;91:2577-2580.

STUDY

Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology.

Macario A, Morris D, Morris S. Arch Surg. 2006;141:659-662.

STUDY

Effect of short-term pretrial practice on surgical proficiency in simulated environments: a randomized trial of the "preoperative warm-up" effect.

Kahol K, Satava RM, Ferrara J, Smith ML. J Am Coll Surg. 2009;208:255-268.

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