AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (166)

•Diagnostic Errors (149)

•Identification Errors (142)

•Discontinuities, Gaps, and Hand-Off Problems (402)

•Fatigue and Sleep Deprivation (97)

•Medication Safety (917)

•Medical Complications (435)

•Nonsurgical Procedural Complications (89)

•Surgical Complications (861)

•Transfusion Complications (19)

•Psychological and Social Complications (162)

Origin/Sponsor

•Africa (6)

•Asia (27)

•Australia and New Zealand (80)

•Central and South America (3)

•Europe (384)

•North America (3527)

Resource Types

•Clinical Guideline (9)

•Journal Article (2741)

•Legislation/Regulation (72)

•Meeting/Conference (47)

•Newsletter/Journal (15)

•Newspaper/Magazine Article (478)

•Press Release/Announcement (32)

•Special or Theme Issue (78)

•Tools/Toolkit (72)

•Web Resource (142)

•Grant (13)

Error Types

•Epidemiology of Errors and Adverse Events (767)

•Active Errors (533)

•Latent Errors (237)

•Near Miss (70)

Approach to Improving Safety

•Quality Improvement Strategies (1063)

•Legal and Policy Approaches (588)

•Error Reporting and Analysis (1150)

•Communication Improvement (1022)

•Human Factors Engineering (570)

•Teamwork (396)

•Specialization of Care (231)

•Logistical Approaches (267)

•Culture of Safety (662)

•Technologic Approaches (635)

•Education and Training (807)

Clinical Areas

•Allied Health Services (13)

Target Audience

•Health Care Providers (3160)

•Health Care Executives and Administrators (3305)

•Non-Health Care Professionals (1697)

•Patients (383)

Setting of Care

•Hospitals (2478)

•Psychiatric Facilities (15)

•Residential Facilities (68)

•Ambulatory Care (325)

•Outpatient Surgery (66)

•Patient Transport (29)

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COMMENTARY

The competent surgeon: individual accountability in the era of "systems" failure.

Whittemore AD. Ann Surg. 2009;250:357-362.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

Bernhard B. The Orange County Register. April 19, 2006.

STUDY

A surgical safety checklist to reduce morbidity and mortality in a global population.

Haynes AB, Weiser TG, Berry WR, et al; for the Safe Surgery Saves Lives Study Group. N Engl J Med. 2009;360:491-499.

COMMENTARY

Resident duty hours in surgery for ensuring patient safety, providing optimum resident education and training, and promoting resident well-being: a response from the American College of Surgeons to the Report of the Institute of Medicine, "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety."

Britt LD, Sachdeva AK, Healy GB, Whalen TV, Blair PG; Members of the ACS Task Force on Resident Duty Hours. Surgery. 2009;146:398-409.

REVIEW

Requirements for the design and implementation of checklists for surgical processes.

Verdaasdonk EGG, Stassen LPS, Widhiasmara PP, Dankelman J. Surg Endosc. 2009;23:715-726.

BOOK/REPORT

Safe Surgery Guide.

Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404073.

COMMENTARY

Cutting out human error.

Feinmann J. BMJ. 2008;337:a2370.

BOOK/REPORT

Back to Basics.

Gima Z, Gosselar P, Levine A, Lincoln T, Ramirez A. Washington, DC: Public Citizen; August 6, 2009.

STUDY

Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention.

Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. BMJ Qual Saf. 2011;20:102-107.

SPECIAL OR THEME ISSUE

Patient Safety.

Martin RF, Sanchez JA, eds. Surg Clin North Am. 2012;92:1-177.

COMMENTARY

How long does it take to train a surgeon?

Purcell Jackson G, Tarpley JL. BMJ. 2009;339:b4260.

STUDY

Errors with concentrated epinephrine in otolaryngology.

Shah RK, Hoy E, Roberson DW, Nielsen D. Laryngoscope. 2008 Nov; 118: 1928-30.

STUDY

Improving operating room safety.

Hurlbert SN, Garrett J. Patient Saf Surg. 2009;3:25.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

COMMENTARY

Clinical care checklists: salvations or frustrations?

Jones JW, McCullough LB. J Vasc Surg. 2011;53:1429-1430.

STUDY

Crisis checklists for the operating room: development and pilot testing.

Ziewacz JE, Arriaga AF, Bader AM, et al. J Am Coll Surg. 2011;213:212-219.

BOOK/REPORT

MHA Keystone Center for Patient Safety & Quality 2010 Annual Report.

Lansing, MI: Michigan Health & Hospital Association; October 2010.

BOOK/REPORT classic

The Checklist Manifesto: How to Get Things Right.

Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.

AUDIOVISUAL

The power of checklists.

Gawande A, Weinstock M. Hosp Health Netw. July 27, 2011.

MULTI-USE WEBSITE

Safe Surgery Saves Lives.

Canadian Patient Safety Institute.

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