AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (138)

•Diagnostic Errors (155)

•Identification Errors (155)

•Discontinuities, Gaps, and Hand-Off Problems (288)

•Fatigue and Sleep Deprivation (65)

•Medication Safety (720)

•Medical Complications (310)

•Nonsurgical Procedural Complications (87)

•Surgical Complications (721)

•Transfusion Complications (16)

•Psychological and Social Complications (104)

Origin/Sponsor

•Africa (4)

•Asia (48)

•Australia and New Zealand (104)

•Central and South America (9)

•Europe (496)

•North America (1926)

Resource Types

•Audiovisual (16)

•Award (10)

•Book/Report (106)

•Clinical Guideline (7)

•Journal Article (2081)

•Legislation/Regulation (34)

•Meeting/Conference (13)

•Newsletter/Journal (7)

•Newspaper/Magazine Article (205)

•Press Release/Announcement (28)

•Special or Theme Issue (42)

•Tools/Toolkit (43)

•Web Resource (76)

•Grant (6)

Error Types

•Epidemiology of Errors and Adverse Events (716)

•Active Errors (735)

•Latent Errors (209)

•Near Miss (112)

Approach to Improving Safety

•Quality Improvement Strategies (667)

•Legal and Policy Approaches (194)

•Error Reporting and Analysis (767)

•Communication Improvement (761)

•Human Factors Engineering (477)

•Teamwork (435)

•Specialization of Care (162)

•Logistical Approaches (177)

•Culture of Safety (319)

•Technologic Approaches (418)

•Education and Training (553)

Clinical Areas

•Allied Health Services (12)

Target Audience

•Health Care Providers (2175)

•Health Care Executives and Administrators (2359)

•Non-Health Care Professionals (899)

•Patients (152)

Setting of Care

•Hospitals (1853)

•Psychiatric Facilities (10)

•Residential Facilities (42)

•Ambulatory Care (190)

•Outpatient Surgery (43)

•Patient Transport (27)

1 - 20 of 2674

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COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

STUDY

Operating room briefings and wrong-site surgery.

Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.

REVIEW

Avoiding wrong site surgery: a systematic review.

DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.

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

Wrong-site craniotomy: analysis of 35 cases and systems for prevention.

Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473.

ORGANIZATIONAL POLICY/GUIDELINES

Safe Site Invasive Procedure—Non-Operating Room.

Bloomington, MN: Institute for Clinical Systems Improvement; 2010.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals collaborate to prevent wrong-site surgery.

Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.

REVIEW

Determining the state of knowledge for implementing the Universal Protocol recommendations: an integrative review of the literature.

Conrardy JA, Brenek B, Myers S. AORN J. 2010;92:194-207.

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

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.

REVIEW

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.

STUDY

Variation in surgical time-out and site marking within pediatric otolaryngology.

Shah RK, Arjmand E, Roberson DW, Deutsch E, Derkay C. Arch Otolaryngol Head Neck Surg. 2011;137:69-73.

COMMENTARY classic

A 62-year-old woman with skin cancer who experienced wrong-site surgery.

Gallagher TH. JAMA. 2009;302:669-677.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

NEWSPAPER/MAGAZINE ARTICLE

The pain of wrong site surgery.

Boodman SG. Washington Post. June 21, 2011:E1.

COMMENTARY

Mark My Limb.

O'Leary DS, Jacott WE. AHRQ WebM&M [serial online]. December 2004.

STUDY

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

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

STUDY

Nature, causes and consequences of unintended events in surgical units.

van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Br J Surg. 2010;97:1730-1740.

COMMENTARY

Wrong site surgery.

Fraser SG, Adams W. Br J Ophthalmol. 2006;90:814-816.

STUDY

Wrong-site sinus surgery in otolaryngology.

Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.

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