AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (104)

•Diagnostic Errors (116)

•Identification Errors (84)

•Discontinuities, Gaps, and Hand-Off Problems (276)

•Fatigue and Sleep Deprivation (96)

•Medication Safety (657)

•Medical Complications (295)

•Nonsurgical Procedural Complications (71)

•Surgical Complications (357)

•Transfusion Complications (12)

•Psychological and Social Complications (153)

Origin/Sponsor

•Asia (26)

•Australia and New Zealand (39)

•Central and South America (2)

•Europe (195)

•North America (2609)

Resource Types

•Clinical Guideline (2)

•Journal Article (2253)

•Legislation/Regulation (32)

•Meeting/Conference (23)

•Newsletter/Journal (6)

•Newspaper/Magazine Article (234)

•Press Release/Announcement (10)

•Special or Theme Issue (55)

•Tools/Toolkit (27)

•Web Resource (59)

•Grant (7)

Error Types

•Epidemiology of Errors and Adverse Events (535)

•Active Errors (390)

•Latent Errors (153)

•Near Miss (51)

Approach to Improving Safety

•Quality Improvement Strategies (950)

•Legal and Policy Approaches (204)

•Error Reporting and Analysis (733)

•Communication Improvement (664)

•Human Factors Engineering (351)

•Teamwork (412)

•Specialization of Care (170)

•Logistical Approaches (233)

•Culture of Safety (495)

•Technologic Approaches (399)

•Education and Training (873)

Clinical Areas

•Allied Health Services (7)

Target Audience

•Health Care Providers (1848)

•Health Care Executives and Administrators (2536)

•Non-Health Care Professionals (1525)

•Patients (94)

Setting of Care

•Hospitals (1739)

•Psychiatric Facilities (7)

•Residential Facilities (45)

•Ambulatory Care (179)

•Outpatient Surgery (21)

•Patient Transport (17)

1 - 20 of 2877

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STUDY

The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases.

Wolf FA, Way LW, Stewart L. Ann Surg. 2010;252:477-485.

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

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

Crew resource management improved perception of patient safety in the operating room.

Gore DC, Powell JM, Baer JG, et al. Am J Med Qual. 2010;25:60-63.

REVIEW

Enhancing communication in surgery through team training interventions: a systematic literature review.

Gillespie BM, Chaboyer W, Murray P. AORN J. 2010;92:642-657.

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.

BOOK/REPORT

Achieving Strong Teamwork Practices in Hospital Labor and Delivery Units.

Farley DO, Sorbero ME, Lovejoy SL, Salisbury M. Santa Monica, CA: Rand Corporation; 2010. ISBN: 9780833050557.

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.

COMMENTARY

Handoffs and communication: the underappreciated roles of situational awareness and inattentional blindness.

Gosbee J. Clin Obstet Gynecol. 2010;53:545-558.

REVIEW

Does crew resource management training work? An update, an extension, and some critical needs.

Salas E, Wilson KA, Burke CS, Wightman DC. Hum Factors. 2006;48:392-412.

STUDY

Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations.

Thomas EJ, Williams AL, Reichman EF, Lasky RE, Crandell S, Taggart WR. Pediatrics. 2010;125:539-546.

COMMENTARY

High-performance teams and the physician leader: an overview.

Majmudar A, Jain AK, Chaudry J, Schwartz RW. J Surg Educ. 2010;67:205-209.

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

Impact of a comprehensive patient safety strategy on obstetric adverse events.

Pettker CM, Thung SF, Norwitz ER, et al. Am J Obstet Gynecol. 2009 May;200:492.e1-8.

STUDY

Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study.

Paine LA, Rosenstein BJ, Sexton JB, Kent P, Holzmueller CG, Pronovost PJ. Qual Saf Health Care. 2010;19:547-554.

STUDY

Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital.

Riley W, Davis S, Miller K, Hansen H, Sainfort F, Sweet R. Jt Comm J Qual Patient Saf. 2011;37:357-364.

STUDY

Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training Program improves the cardiopulmonary resuscitation code process.

Percarpio KB, Harris FS, Hatfield BA, et al. Jt Comm J Qual Patient Saf. 2010;36:424-429:AP1.

COMMENTARY

Reducing medical error in the Military Health System: how can team training help?

Alonso A, Baker DP, Holtzman A, et al. Hum Resource Manage Rev. 2006;16:396-415.

COMMENTARY

Enhancing patient safety in the pediatric emergency department: teams, communication, and lessons from crew resource management.

Pruitt CM, Liebelt EL. Pediatr Emerg Care. 2010;26:942-948.

STUDY

Assessing teamwork attitudes in healthcare: development of the TeamSTEPPS teamwork attitudes questionnaire.

Baker DP, Amodeo AM, Krokos KJ, Slonim A, Herrera H. Qual Saf Health Care. 2010;19:e49.

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