AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (156)

•Diagnostic Errors (197)

•Identification Errors (141)

•Discontinuities, Gaps, and Hand-Off Problems (457)

•Fatigue and Sleep Deprivation (132)

•Medication Safety (1055)

•Medical Complications (424)

•Nonsurgical Procedural Complications (89)

•Surgical Complications (810)

•Transfusion Complications (17)

•Psychological and Social Complications (283)

Origin/Sponsor

•Africa (2)

•Asia (55)

•Australia and New Zealand (99)

•Central and South America (6)

•Europe (468)

•North America (3360)

Resource Types

•Audiovisual (29)

•Award (10)

•Book/Report (143)

•Clinical Guideline (4)

•Journal Article (3288)

•Legislation/Regulation (47)

•Meeting/Conference (18)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (330)

•Press Release/Announcement (11)

•Special or Theme Issue (55)

•Tools/Toolkit (32)

•Web Resource (66)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (1377)

•Active Errors (619)

•Latent Errors (208)

•Near Miss (72)

Approach to Improving Safety

•Quality Improvement Strategies (859)

•Legal and Policy Approaches (282)

•Error Reporting and Analysis (1162)

•Communication Improvement (1083)

•Human Factors Engineering (520)

•Teamwork (454)

•Specialization of Care (232)

•Logistical Approaches (344)

•Culture of Safety (528)

•Technologic Approaches (590)

•Education and Training (1019)

Clinical Areas

•Allied Health Services (13)

Target Audience

•Health Care Providers (2705)

•Health Care Executives and Administrators (3229)

•Non-Health Care Professionals (1775)

•Patients (226)

Setting of Care

•Hospitals (2668)

•Psychiatric Facilities (9)

•Residential Facilities (62)

•Ambulatory Care (303)

•Outpatient Surgery (50)

•Patient Transport (30)

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STUDY

A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative.

Arriaga AF, Elbardissi AW, Regenbogen SE, et al. Ann Surg. 2011;253:849-854.

STUDY

Framing family conversation after early diagnosis of iatrogenic injury and incidental findings.

Barrios L, Tsuda S, Derevianko A, et al. Surg Endosc. 2009;23:2535-2542.

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

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

The influence of resident involvement on surgical outcomes.

Raval MV, Wang X, Cohen ME, et al. J Am Coll Surg. 2011;212:889-898.

STUDY

The "July phenomenon": is trauma the exception?

Schroeppel TJ, Fischer PE, Magnotti LJ, Croce MA, Fabian TC. J Am Coll Surg. 2009;209:378-384.

STUDY

Attitudinal changes resulting from repetitive training of operating room personnel using high-fidelity simulation at the point of care.

Paige JT, Kozmenko V, Yang T, et al. Am Surg. 2009;75:584-591.

STUDY

Optimising surgical training: use of feedback to reduce errors during a simulated surgical procedure.

Boyle E, Al-Akash M, Gallagher AG, Traynor O, Hill AD, Neary PC. Postgrad Med J. 2011;87:524-528.

STUDY

Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results.

Telem DA, Buch KE, Ellis S, Coakley B, Divino CM. Arch Surg. 2011;146:89-93.

STUDY

Resident participation does not affect surgical outcomes, despite introduction of new techniques.

Patel SP, Gauger PG, Brown DL, Englesbe MJ, Cederna PS. J Am Coll Surg. 2010;211:540-545.

COMMENTARY

What happens when things go wrong?

Brandom BW, Callahan P, Micalizzi DA. Paediatr Anaesth. 2011;21:730-736.

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

Patient safety climate among orthopaedic surgery residents.

Kadzielski J, McCormick F, Zurakowski D, Herndon JH. J Bone Joint Surg Am. 2011;93:e621-e626.

STUDY

The impact of the 80-hour work week on appropriate resident case coverage.

Shin S, Britt R, Doviak M, Britt LD. J Surg Res. 2010;162:33-36.

STUDY

Burnout and medical errors among American surgeons.

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

STUDY

Does teamwork improve performance in the operating room? A multilevel evaluation.

Weaver SJ, Rosen MA, DiazGranados D, et al. Jt Comm J Qual Patient Saf. 2010;36:133-142.

STUDY

Violations of behavioral practices revealed in closed claims reviews.

Griffen FD, Stephens LS, Alexander JB, et al. Ann Surg. 2008;248:468-474.

STUDY

A novel method for reproducibly measuring the effects of interventions to improve emotional climate, indices of team skills and communication, and threat to patient outcome in a high-volume thoracic surgery center.

Nurok M, Lipsitz S, Satwicz P, Kelly A, Frankel A. Arch Surg. 2010;145:489-495.

STUDY

Communication failure in the operating room.

Halverson AL, Casey JT, Andersson J, et al. Surgery. 2011;49:305-310.

STUDY

Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme.

Neily J, Mills PD, Lee P, et al. Qual Saf Health Care. 2010;19:360-364.

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