AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (95)

•Diagnostic Errors (144)

•Identification Errors (106)

•Discontinuities, Gaps, and Hand-Off Problems (324)

•Fatigue and Sleep Deprivation (94)

•Medication Safety (599)

•Medical Complications (195)

•Nonsurgical Procedural Complications (47)

•Surgical Complications (675)

•Transfusion Complications (7)

•Psychological and Social Complications (105)

Origin/Sponsor

•Asia (18)

•Australia and New Zealand (32)

•Central and South America (2)

•Europe (184)

•North America (2070)

Resource Types

•Audiovisual (22)

•Award (2)

•Book/Report (55)

•Clinical Guideline (12)

•Journal Article (1822)

•Legislation/Regulation (43)

•Meeting/Conference (7)

•Newsletter/Journal (6)

•Newspaper/Magazine Article (269)

•Press Release/Announcement (14)

•Special or Theme Issue (31)

•Tools/Toolkit (34)

•Web Resource (42)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (424)

•Active Errors (428)

•Latent Errors (136)

•Near Miss (43)

Approach to Improving Safety

•Quality Improvement Strategies (633)

•Legal and Policy Approaches (176)

•Error Reporting and Analysis (574)

•Communication Improvement (649)

•Human Factors Engineering (328)

•Teamwork (233)

•Specialization of Care (102)

•Logistical Approaches (232)

•Culture of Safety (244)

•Technologic Approaches (348)

•Education and Training (502)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (2094)

•Health Care Executives and Administrators (1614)

•Non-Health Care Professionals (654)

•Patients (173)

Setting of Care

•Hospitals (1542)

•Psychiatric Facilities (7)

•Residential Facilities (24)

•Ambulatory Care (153)

•Outpatient Surgery (39)

•Patient Transport (8)

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COMMENTARY

A nurse-led approach to developing and implementing a collaborative count policy.

Norton EK, Micheli AJ, Gedney J, Felkerson TM. AORN J. 2012;95:222-227.

STUDY

Risk factors associated with incorrect surgical counts.

Rowlands A. AORN J. 2012;96:272-284.

COMMENTARY

Counting for patient safety.

Watson DS. AORN J. 2006;84:273-275.

STUDY

Governing the surgical count through communication interactions: implications for patient safety.

Riley R, Manias E, Polglase A. Qual Saf Health Care. 2006;15:369-374.

ORGANIZATIONAL POLICY/GUIDELINES

Statement on the prevention of retained foreign bodies after surgery.

Bulletin of the American College of Surgeons; October 2005.

STUDY

Effectiveness of a radiofrequency detection system as an adjunct to manual counting protocols for tracking surgical sponges: a prospective trial of 2,285 patients.

Rupp CC, Kagarise MJ, Nelson SM, et al. J Am Coll Surg. 2012;215:524-533.

COMMENTARY

On the quest for Six Sigma.

Moorman DW. Am J Surg. 2005;189:253-258.

ORGANIZATIONAL POLICY/GUIDELINES

Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society.

Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF. J Am Coll Surg. 2012;215:453-466.

COMMENTARY

Implementing AORN recommended practices for prevention of retained surgical items.

Goldberg JL, Feldman DL. AORN J. 2012;95:205-219.

STUDY

Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors' and nurses' views.

McDonald R, Waring J, Harrison S, Walshe K, Boaden R. Qual Saf Health Care. 2005;14:290-294.

NEWSPAPER/MAGAZINE ARTICLE

Safety in ASCs: putting patients first.

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

STUDY

Incorrect surgical counts: a qualitative analysis.

Rowlands A, Steeves R. AORN J. 2010;92:410-419.

COMMENTARY

Increasing patient safety and surgical team communication by using a count/time out board.

Edel EM. AORN J. 2010;92:420-424.

CLINICAL GUIDELINE

Practice Advisory on Intraoperative Awareness and Brain Function Monitoring.

ASA Task Force on Intraoperative Awareness and Brain Function Monitoring. Park Ridge, IL: American Society of Anesthesiologists; July 2005.

NEWSPAPER/MAGAZINE ARTICLE

Bringing surgeons down to earth.

Landro L. Wall Street Journal (Eastern edition). November 16, 2005:D1.

STUDY

Incidence, patterns, and prevention of wrong-site surgery.

Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.

COMMENTARY

The normalization of deviance: what are the perioperative risks?

McNamara SA. AORN J. 2011;93:796-801.

MULTI-USE WEBSITE

Surgical Care Improvement Project.

National SCIP Partnership, Oklahoma Foundation for Medical Quality, 14000 Quail Springs Parkway, Suite 400, Oklahoma City, OK, 73134.

STUDY

Observational assessment of surgical teamwork: a feasibility study.

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

NEWSPAPER/MAGAZINE ARTICLE

Surgery fires spur need for new guidelines.

Collins D. Associated Press [MSNBC]. July 26, 2007.

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