AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (8)

•Diagnostic Errors (5)

•Identification Errors (17)

•Discontinuities, Gaps, and Hand-Off Problems (34)

•Fatigue and Sleep Deprivation (16)

•Medication Safety (22)

•Medical Complications (13)

•Nonsurgical Procedural Complications (4)

•Surgical Complications (338)

•Psychological and Social Complications (24)

Origin/Sponsor

•Africa (1)

•Asia (7)

•Australia and New Zealand (11)

•Europe (152)

•North America (241)

Resource Types
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Study

Error Types

•Epidemiology of Errors and Adverse Events (143)

•Active Errors (54)

•Latent Errors (21)

•Near Miss (11)

Approach to Improving Safety

•Quality Improvement Strategies (69)

•Legal and Policy Approaches (17)

•Error Reporting and Analysis (118)

•Communication Improvement (128)

•Human Factors Engineering (81)

•Teamwork (97)

•Specialization of Care (10)

•Logistical Approaches (29)

•Culture of Safety (44)

•Technologic Approaches (30)

•Education and Training (104)

Clinical Areas

•Allied Health Services (1)

•Medicine (407)

•Nursing (28)

•Pharmacy (1)

Target Audience

•Health Care Providers (305)

•Health Care Executives and Administrators (330)

•Non-Health Care Professionals (156)

•Patients (2)

Setting of Care

•Hospitals (382)

•Ambulatory Care (2)

•Outpatient Surgery (12)

•Patient Transport (3)

1 - 20 of 412

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STUDY

Development of a rating system for surgeons' non-technical skills.

Yule S, Flin R, Paterson-Brown S, Maran N, Rowley D. Med Educ. 2006;40:1098-1104.

STUDY

Use of briefings and debriefings as a tool in improving team work, efficiency, and communication in the operating theatre.

Bethune R, Sasirekha G, Sahu A, Cawthorn S, Pullyblank A. Postgrad Med J. 2011;87:331-334.

STUDY

Multidisciplinary crisis simulations: the way forward for training surgical teams.

Undre S, Koutantji M, Sevdalis N, et al. World J Surg. 2007;31:1843-1853.

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

Teamwork and error in the operating room: analysis of skills and roles.

Catchpole K, Mishra A, Handa A, McCulloch P. Ann Surg. 2008;247:699-706.

STUDY

Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.

Steinberger DM, Douglas SV, Kirschbaum MS. Prog Transplant. 2009;19:208-215.

STUDY

A systematic proactive risk assessment of hazards in surgical wards: a quantitative study.

Anderson O, Brodie A, Vincent CA, Hanna GB. Ann Surg. 2012;255:1086-1092.

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

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

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

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

Factors influencing incident reporting in surgical care.

Kreckler S, Catchpole K, McCulloch P, Handa A. Qual Saf Health Care. 2009;18:116-120.

STUDY

Action research, simulation, team communication, and bringing the tacit into voice. Society for Simulation in Healthcare.

Forsythe L. Simul Healthc. 2009;4:143-148.

STUDY

Surgical skill is predicted by the ability to detect errors.

Bann S, Khan M, Datta V, Darzi A. Am J Surg. 2005;189:412-415.

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

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

The introduction of a surgical safety checklist in a tertiary referral obstetric centre.

Kearns RJ, Uppal V, Bonner J, Robertson J, Daniel M, McGrady EM. BMJ Qual Saf. 2011;20:818-822.

STUDY

Improving patient safety by identifying latent failures in successful operations.

Catchpole KR, Giddings AE, Wilkinson M, Hirst G, Dale T, de Leval MR. Surgery. 2007;142:102-110.

STUDY

Attitudes to teamwork and safety in the operating theatre.

Flin R, Yule S, McKenzie L, Paterson-Brown S, Maran N. Surgeon. June 2006;4:145-151.

STUDY

Mapping changes in surgical mortality over 9 years by peer review audit.

Thompson AM, Ashraf Z, Burton H, Stonebridge PA. Br J Surg. 2005;92:1449-1452.

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