AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (143)

•Diagnostic Errors (166)

•Identification Errors (127)

•Discontinuities, Gaps, and Hand-Off Problems (340)

•Fatigue and Sleep Deprivation (131)

•Medication Safety (887)

•Medical Complications (345)

•Nonsurgical Procedural Complications (56)

•Surgical Complications (645)

•Transfusion Complications (15)

•Psychological and Social Complications (166)

Origin/Sponsor

•Africa (3)

•Asia (20)

•Australia and New Zealand (47)

•Central and South America (4)

•Europe (212)

•North America (3485)

Resource Types

•Clinical Guideline (9)

•Journal Article (2391)

•Legislation/Regulation (61)

•Meeting/Conference (31)

•Newsletter/Journal (15)

•Newspaper/Magazine Article (648)

•Press Release/Announcement (28)

•Special or Theme Issue (62)

•Tools/Toolkit (67)

•Web Resource (113)

•Grant (7)

Error Types

•Epidemiology of Errors and Adverse Events (595)

•Active Errors (451)

•Latent Errors (214)

•Near Miss (49)

Approach to Improving Safety

•Quality Improvement Strategies (930)

•Legal and Policy Approaches (672)

•Error Reporting and Analysis (1073)

•Communication Improvement (850)

•Human Factors Engineering (417)

•Teamwork (301)

•Specialization of Care (205)

•Logistical Approaches (298)

•Culture of Safety (565)

•Technologic Approaches (576)

•Education and Training (739)

Clinical Areas

•Allied Health Services (11)

Target Audience

•Health Care Providers (2722)

•Health Care Executives and Administrators (2835)

•Non-Health Care Professionals (1482)

•Patients (681)

Setting of Care

•Hospitals (2231)

•Psychiatric Facilities (12)

•Residential Facilities (56)

•Ambulatory Care (250)

•Outpatient Surgery (47)

•Patient Transport (11)

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NEWSPAPER/MAGAZINE ARTICLE

'Wrong site' surgeries on the rise.

Davis R. USA Today. April 17, 2006.

COMMENTARY

Surgical site verification: A through Z.

Dunn D. J Perianesth Nurs. 2006;21:317-328.

ORGANIZATIONAL POLICY/GUIDELINES classic

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.

The Joint Commission.

NEWSPAPER/MAGAZINE ARTICLE

When surgery goes wrong: weighing up the risks.

Feinmann J. The Independent. November 14, 2006.

COMMENTARY

Our broken health care system and how to fix it: an essay on health law and policy.

Jost TS. Wake Forest Law Rev. 2006;41:537-618.

STUDY

When the bone flap hits the floor.

Jankowitz BT, Kondziolka DS. Neurosurgery. 2006;59:585-590.

NEWSPAPER/MAGAZINE ARTICLE

Tomorrow's operating room to harness Net, RFID.

Olsen S. CNET News.com; October 19, 2005.

COMMENTARY

Collegiality vs. Competence

Sagin T. AHRQ WebM&M [serial online]. March 2006.

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

Errors with concentrated epinephrine in otolaryngology.

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

REVIEW

Role of intraoperative cholangiography in avoiding bile duct injury.

Massarweh NN, Flum DR. J Am Coll Surg. 2007;204:656-664.

BOOK/REPORT

To Err Is Human — To Delay Is Deadly.

Jewell K, McGiffert L. Austin, TX: Consumers Union; 2009.

NEWSPAPER/MAGAZINE ARTICLE

M.R.I.'s strong magnets cited in accidents.

McNeil DG Jr. New York Times. August 19, 2005;National Desk section:1.

NEWSPAPER/MAGAZINE ARTICLE

New practices reduce childbirth risks.

Landro L. Wall Street Journal. July 12, 2006:D1. [Reprinted on Post-gazette.com].

NEWSPAPER/MAGAZINE ARTICLE

Surgery fires spur need for new guidelines.

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

STUDY

Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.

Hu YY, Arriaga AF, Roth EM, et al. Ann Surg. 2012;256:203-210.

COMMENTARY

Constitutional arguments in favor of modifying the HCQIA to allow the dissemination of physician information to healthcare consumers.

Chernitsky LA. Wash Lee Law Rev. Spring 2006;63:737-776.

COMMENTARY

"Health courts" and accountability for patient safety.

Mello MM, Studdert DM, Kachalia AB, Brennan TA. Milbank Q. 2006;84:459-492.

STUDY

Error, stress, and teamwork in medicine and aviation: cross sectional surveys.

Sexton JB, Thomas EJ, Helmreich RL. BMJ. 2000;320:745-749.

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