AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (113)

•Diagnostic Errors (146)

•Identification Errors (97)

•Discontinuities, Gaps, and Hand-Off Problems (347)

•Fatigue and Sleep Deprivation (109)

•Medication Safety (749)

•Medical Complications (289)

•Nonsurgical Procedural Complications (66)

•Surgical Complications (735)

•Transfusion Complications (9)

•Psychological and Social Complications (151)

Origin/Sponsor

•Africa (2)

•Asia (40)

•Australia and New Zealand (68)

•Central and South America (4)

•Europe (283)

•North America (2700)

Resource Types

•Audiovisual (35)

•Award (16)

•Book/Report (128)

•Clinical Guideline (9)

•Journal Article (2380)

•Legislation/Regulation (35)

•Meeting/Conference (14)

•Newsletter/Journal (6)

•Newspaper/Magazine Article (350)

•Press Release/Announcement (12)

•Special or Theme Issue (65)

•Tools/Toolkit (44)

•Web Resource (48)

•Grant (6)

Error Types

•Epidemiology of Errors and Adverse Events (525)

•Active Errors (424)

•Latent Errors (189)

•Near Miss (57)

Approach to Improving Safety

•Quality Improvement Strategies (736)

•Legal and Policy Approaches (271)

•Error Reporting and Analysis (797)

•Communication Improvement (937)

•Human Factors Engineering (430)

•Teamwork (505)

•Specialization of Care (162)

•Logistical Approaches (303)

•Culture of Safety (779)

•Technologic Approaches (417)

•Education and Training (732)

Clinical Areas

•Allied Health Services (11)

Target Audience

•Health Care Providers (2512)

•Health Care Executives and Administrators (2316)

•Non-Health Care Professionals (1063)

•Patients (216)

Setting of Care

•Hospitals (1980)

•Psychiatric Facilities (9)

•Residential Facilities (47)

•Ambulatory Care (206)

•Outpatient Surgery (47)

•Patient Transport (12)

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STUDY

Causes of near misses: perceptions of perioperative nurses.

Cohoon B. AORN J. 2011;93:551-565.

STUDY

Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork.

Vogelsmeier A, Scott-Cawiezell J. J Nurs Care Qual. 2011;26:236-242.

COMMENTARY

"Managing up" can improve teamwork in the OR.

Smith SL. AORN J. 2010;91:576-582.

STUDY

Nurses' and nursing assistants' perceptions of patient safety culture in nursing homes.

Hughes CM, Lapane KL. Int J Qual Health Care. 2006;18:281-286.

REVIEW

The Nurse's Role in Promoting a Culture of Patient Safety.

Friesen MA, Farquhar MB, Hughes R. American Nurses Association (ANA) Continuing Education, Center for American Nurses; 2005.

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

Costly issues of an uncommunicative OR.

Neil R. Mat Manage Health Care. March 2006;15:30-33.

ORGANIZATIONAL POLICY/GUIDELINES

AORN guidance statement: creating a patient safety culture.

AORN J. 2006;83:936-942.

REVIEW

Communication and teamwork in patient care: how much can we learn from aviation?

Lyndon A. J Obset Gynol Neonatal Nurs. 2006;35:538-546.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

Bernhard B. The Orange County Register. April 19, 2006.

STUDY

Action research, simulation, team communication, and bringing the tacit into voice. Society for Simulation in Healthcare.

Forsythe L. Simul Healthc. 2009;4:143-148.

COMMENTARY

The normalization of deviance: what are the perioperative risks?

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

STUDY

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

Sexton JB, Makary MA, Tersigni AR, et al. Anesthesiology. 2006;105:877-884.

STUDY

Nurse and nurse assistant perceptions of missed nursing care: what does it tell us about teamwork?

Kalisch BJ. J Nurs Adm. 2009;39:485-493.

STUDY

Communication practices on 4 Harvard surgical services: a surgical safety collaborative.

ElBardissi AW, Regenbogen SE, Greenberg CC, et al. Ann Surg. 2009;250:861-865.

COMMENTARY

Safety huddles in the PACU: when a patient self-medicates.

Setaro J, Connolly M. J Perianesth Nurs. 2011;26:96-102.

COMMENTARY

A common body of care: the ethics and politics of teamwork in the operating theater are inseparable.

Bleakley A. J Med Philos. 2006;31:305-322.

STUDY

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

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

COMMENTARY

Framework for patient safety—part 1 and part 2.

Blouin AS, McDonagh KJ. J Nurs Adm. 2011;41:397-400, 450-452.

MEETING/CONFERENCE PROCEEDINGS

Safety in the NICU: preventing medical errors.

Stokowski LA. Highlights of the National Association of Neonatal Nurses 22nd Annual Conference [Medscape.com]. March 8, 2007.

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