AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (79)

•Diagnostic Errors (122)

•Identification Errors (95)

•Discontinuities, Gaps, and Hand-Off Problems (163)

•Fatigue and Sleep Deprivation (76)

•Medication Safety (373)

•Medical Complications (141)

•Nonsurgical Procedural Complications (44)

•Surgical Complications (759)

•Transfusion Complications (10)

•Psychological and Social Complications (74)

Origin/Sponsor

•Africa (2)

•Asia (31)

•Australia and New Zealand (55)

•Central and South America (3)

•Europe (397)

•North America (1230)

Resource Types

•Audiovisual (15)

•Award (2)

•Book/Report (44)

•Clinical Guideline (6)

•Journal Article (1448)

•Legislation/Regulation (20)

•Meeting/Conference (1)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (157)

•Press Release/Announcement (14)

•Special or Theme Issue (20)

•Tools/Toolkit (19)

•Web Resource (27)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (510)

•Active Errors (331)

•Latent Errors (110)

•Near Miss (42)

Approach to Improving Safety

•Quality Improvement Strategies (393)

•Legal and Policy Approaches (135)

•Error Reporting and Analysis (628)

•Communication Improvement (394)

•Human Factors Engineering (307)

•Teamwork (197)

•Specialization of Care (65)

•Logistical Approaches (125)

•Culture of Safety (185)

•Technologic Approaches (226)

•Education and Training (346)

Clinical Areas

•Allied Health Services (2)

Target Audience

•Health Care Providers (1300)

•Health Care Executives and Administrators (1522)

•Non-Health Care Professionals (567)

•Patients (101)

Setting of Care

•Hospitals (1245)

•Psychiatric Facilities (4)

•Residential Facilities (12)

•Ambulatory Care (74)

•Outpatient Surgery (43)

•Patient Transport (9)

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STUDY

Prevention of surgical malpractice claims by a surgical safety checklist.

de Vries EN, Eikens-Jansen MP, Hamersma AM, Smorenburg SM, Gouma DJ, Boermeester MA. Ann Surg. 2011;253:624-628.

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.

NEWSPAPER/MAGAZINE ARTICLE

Costly issues of an uncommunicative OR.

Neil R. Mat Manage Health Care. March 2006;15:30-33.

STUDY

Observational assessment of surgical teamwork: a feasibility study.

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

BOOK/REPORT

Annual Benchmarking Report: Malpractice Risks in Surgery.

Cambridge, MA: CRICO/RMF Strategies; 2010.

STUDY

Wubben I, van Manen JG, van den Akker BJ, Vaartjes SR, van Harten WH. Qual Saf Health Care. 2010;19:e64.

STUDY

Representative case series from public hospital admissions 1998 II: surgical adverse events.

Briant R, Morton J, Lay-Yee R, Davis P, Ali W. N Z Med J. 2005;118:U1591.

STUDY

Time of day effects on the incidence of anesthetic adverse events.

Wright MC, Phillips-Bute B, Mark JB, et al. Qual Saf Health Care. 2006;15:258-263.

REVIEW

Reducing errors in emergency surgery.

Watters DA, Truskett PG. ANZ J Surg. 2013;83:434-437.

STUDY

Incidence, nature and impact of error in surgery.

Bosma E, Veen EJ, Roukema JA. Br J Surg. 2011;98:1654-1659.

STUDY

Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program.

Kiran RP, Ahmed Ali U, Coffey JC, Vogel JD, Pokala N, Fazio VW. Ann Surg. 2012;256:469-475.

STUDY

Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit.

McCulloch P, Kreckler S, New S, Sheena Y, Handa A, Catchpole K. BMJ. 2010;341:c5469.

STUDY

Retained surgical items: a problem yet to be solved.

Stawicki SP, Moffatt-Bruce SD, Ahmed HM, et al. J Am Coll Surg. 2013;216:15-22.

STUDY

Persistent next-day effects of excessive alcohol consumption on laparoscopic surgical performance.

Gallagher AG, Boyle E, Toner P, et al. Arch Surg. 2011;146:419-426.

NEWSPAPER/MAGAZINE ARTICLE

Safety in ASCs: putting patients first.

Dix K. Today's Surgicenter. December 1, 2006.

STUDY

Operating room briefings and wrong-site surgery.

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

STUDY

Burnout and medical errors among American surgeons.

Shanafelt TD, Balch CM, Bechamps G, et al. Ann Surg. 2010;251:995-1000.

STUDY

Prevention of medical accidents caused by defective surgical instruments.

Yasuhara H, Fukatsu K, Komatsu T, Obayashi T, Saito Y, Uetera Y. Surgery. 2012;151:153-161.

STUDY

An evaluation of information transfer through the continuum of surgical care: a feasibility study.

Nagpal K, Vats A, Ahmed K, Vincent C, Moorthy K. Ann Surg. 2010;252:402-407.

NEWSPAPER/MAGAZINE ARTICLE

Surgical errors: new products, protocols help slash the risks.

Williamson JE. Healthcare Purchasing News. January 2006;30:22-25.

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