AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (101)

•Diagnostic Errors (158)

•Identification Errors (118)

•Discontinuities, Gaps, and Hand-Off Problems (246)

•Fatigue and Sleep Deprivation (96)

•Medication Safety (623)

•Medical Complications (177)

•Nonsurgical Procedural Complications (48)

•Surgical Complications (806)

•Transfusion Complications (9)

•Psychological and Social Complications (104)

Origin/Sponsor

•Africa (2)

•Asia (15)

•Australia and New Zealand (36)

•Central and South America (1)

•Europe (214)

•North America (2058)

Resource Types

•Audiovisual (31)

•Award (5)

•Book/Report (64)

•Clinical Guideline (9)

•Journal Article (1771)

•Legislation/Regulation (32)

•Meeting/Conference (5)

•Newsletter/Journal (6)

•Newspaper/Magazine Article (323)

•Press Release/Announcement (5)

•Special or Theme Issue (28)

•Tools/Toolkit (34)

•Web Resource (41)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (509)

•Active Errors (647)

•Latent Errors (168)

•Near Miss (54)

Approach to Improving Safety

•Quality Improvement Strategies (527)

•Legal and Policy Approaches (229)

•Error Reporting and Analysis (664)

•Communication Improvement (605)

•Human Factors Engineering (356)

•Teamwork (224)

•Specialization of Care (98)

•Logistical Approaches (205)

•Culture of Safety (249)

•Technologic Approaches (384)

•Education and Training (488)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (1896)

•Health Care Executives and Administrators (1651)

•Non-Health Care Professionals (732)

•Patients (223)

Setting of Care

•Hospitals (1510)

•Psychiatric Facilities (1)

•Residential Facilities (29)

•Ambulatory Care (201)

•Outpatient Surgery (51)

•Patient Transport (14)

1 - 20 of 2355

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STUDY

Bridging the communication gap in the operating room with medical team training.

Awad SS, Fagan SP, Bellows C, et al. Am J Surg. 2005;190:770-774.

REVIEW

Minimizing surgical error by incorporating objective assessment into surgical education.

Champion HR, Meglan DA, Shair EK. J Am Coll Surg. 2008;207:284-291.

NEWSPAPER/MAGAZINE ARTICLE

Revealing their medical errors: why three doctors went public.

O'Reilly KB. American Medical News. August 15, 2011.

SPECIAL OR THEME ISSUE

Patient Safety and the Invitational Conference on Contemporary Surgical Quality, Safety and Transparency.

Amer Surg. 2006;72:985-1149

NEWSPAPER/MAGAZINE ARTICLE

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

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

COMMENTARY

Implementing the World Health Organization surgical safety checklist: a model for future perioperative initiatives.

Styer KA, Ashley SW, Schmidt S, Zive EM, Eappen S. AORN J. 2011;94:590-598.

BOOK/REPORT

Annual Benchmarking Report: Malpractice Risks in Surgery.

Cambridge, MA: CRICO/RMF Strategies; 2010.

STUDY

Surgical skill is predicted by the ability to detect errors.

Bann S, Khan M, Datta V, Darzi A. Am J Surg. 2005;189:412-415.

STUDY

Expanded surgical time out: a key to real-time data collection and quality improvement.

Altpeter T, Luckhardt K, Lewis JN, Harken AH, Polk HC Jr. J Am Coll Surg. 2007;204:527-532.

STUDY

Waking up the next morning: surgeons' emotional reactions to adverse events.

Luu S, Patel P, St-Martin L, et al. Med Educ. 2012;46:1179-1188.

COMMENTARY

Duke Surgery Patient Safety: an open-source application for anonymous reporting of adverse and near-miss surgical events.

Pietrobon R, Lima R, Shah A, et al. Ann Surg Innov Res. 2007;1:5.

STUDY

Human error, not communication and systems, underlies surgical complications.

Fabri PJ, Zayas-Castro JL. Surgery. 2008;144:557-565.

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

Surgical confusions in ophthalmology.

Simon JW, Ngo Y, Khan S, Strogatz D. Arch Ophthalmol. 2007;125:1515-1522.

STUDY

Surgical specimen identification errors: a new measure of quality in surgical care.

Makary MA, Epstein J, Pronovost PJ, Millman EA, Hartmann EC, Freischlag JA. Surgery. 2007;141:450-455.

REVIEW

Life after death: the aftermath of perioperative catastrophes.

Gazoni FM, Durieux ME, Wells L. Anesth Analg. 2008;107:591-600.

REVIEW

Error training: missing link in surgical education.

DaRosa DA, Pugh CM. Surgery. 2012;151:139-145.

COMMENTARY

Improving operating room and perioperative safety: background and specific recommendations.

Schimpff SC. Surg Innov. 2007;14:127-135.

COMMENTARY classic

Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand.

Ring DC, Herndon JH, Meyer GS. N Engl J Med. 2010;363:1950-1957.

ORGANIZATIONAL POLICY/GUIDELINES

Recommendations for quality assurance and improvement in surgical and autopsy pathology.

Association of Directors of Anatomic and Surgical Pathology. Hum Pathol. 2006;37:985-988.

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