AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (93)

•Diagnostic Errors (121)

•Identification Errors (135)

•Discontinuities, Gaps, and Hand-Off Problems (241)

•Fatigue and Sleep Deprivation (98)

•Medication Safety (614)

•Medical Complications (216)

•Nonsurgical Procedural Complications (50)

•Surgical Complications (807)

•Transfusion Complications (10)

•Psychological and Social Complications (110)

Origin/Sponsor

•Africa (2)

•Asia (32)

•Australia and New Zealand (54)

•Central and South America (3)

•Europe (240)

•North America (2088)

Resource Types

•Audiovisual (25)

•Award (3)

•Book/Report (59)

•Clinical Guideline (9)

•Journal Article (1901)

•Legislation/Regulation (29)

•Meeting/Conference (9)

•Newsletter/Journal (6)

•Newspaper/Magazine Article (277)

•Press Release/Announcement (11)

•Special or Theme Issue (38)

•Tools/Toolkit (35)

•Web Resource (56)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (486)

•Active Errors (396)

•Latent Errors (138)

•Near Miss (47)

Approach to Improving Safety

•Quality Improvement Strategies (533)

•Legal and Policy Approaches (199)

•Error Reporting and Analysis (638)

•Communication Improvement (600)

•Human Factors Engineering (365)

•Teamwork (263)

•Specialization of Care (109)

•Logistical Approaches (250)

•Culture of Safety (281)

•Technologic Approaches (334)

•Education and Training (583)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (2115)

•Health Care Executives and Administrators (1734)

•Non-Health Care Professionals (738)

•Patients (193)

Setting of Care

•Hospitals (1597)

•Psychiatric Facilities (4)

•Residential Facilities (26)

•Ambulatory Care (130)

•Outpatient Surgery (49)

•Patient Transport (7)

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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.

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.

STUDY

Operating room briefings and wrong-site surgery.

Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.

STUDY

Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?

Seiden SC, Barach P. Arch Surg. 2006;141:931-939.

NEWSPAPER/MAGAZINE ARTICLE

'Wrong site' surgeries on the rise.

Davis R. USA Today. April 17, 2006.

NEWSPAPER/MAGAZINE ARTICLE

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

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

TOOLKIT

Perioperative Patient 'Hand-Off' Tool Kit.

Association of Perioperative Registered Nurses.

NEWSPAPER/MAGAZINE ARTICLE

Tomorrow's operating room to harness Net, RFID.

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

STUDY

Perceptions of patient safety culture among physicians and RNs in the perioperative area.

Scherer D, Fitzpatrick JJ. AORN J. 2008;87:163-175.

MULTI-USE WEBSITE

Strong for Surgery.

CERTAIN. Rockville, MD: Agency for Healthcare Research and Quality. SCOAP. Seattle, WA: Foundation for Health Care Quality.

NEWSPAPER/MAGAZINE ARTICLE

Lights. Camera. Robot Action!

Shute N. U.S. News & World Report. January 23, 2006;140:62-63.

MEASUREMENT TOOL/INDICATOR

AORN Evaluation of the Universal Protocol.

Association of PeriOperative Registered Nurses.

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.

STUDY

Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center.

Bandari J, Schumacher K, Simon M, et al. Jt Comm J Qual Patient Saf. 2012;38:154-160.

STUDY

Thirty-day outcomes support implementation of a surgical safety checklist.

Bliss LA, Ross-Richardson CB, Sanzari LJ, et al. J Am Coll Surg. 2012;215:766-776.

STUDY

From the flight deck to the operating room: an initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation.

Paige J, Kozmenko V, Morgan B, et al. J Surg Educ. 2007;64:369-377.

NEWSPAPER/MAGAZINE ARTICLE

Safety in ASCs: putting patients first.

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

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion #464: patient safety in the surgical environment.

ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2010;116:786-790.

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.

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