AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (59)

•Diagnostic Errors (77)

•Identification Errors (120)

•Discontinuities, Gaps, and Hand-Off Problems (217)

•Fatigue and Sleep Deprivation (36)

•Medication Safety (343)

•Medical Complications (142)

•Nonsurgical Procedural Complications (27)

•Surgical Complications (514)

•Transfusion Complications (7)

•Psychological and Social Complications (111)

Origin/Sponsor

•Asia (1)

•Australia and New Zealand (10)

•Europe (65)

•North America (1560)

Resource Types

•Audiovisual (73)

•Award (10)

•Book/Report (98)

•Clinical Guideline (3)

•Journal Article (884)

•Legislation/Regulation (18)

•Meeting/Conference (5)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (440)

•Press Release/Announcement (3)

•Special or Theme Issue (15)

•Tools/Toolkit (36)

•Web Resource (58)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (257)

•Active Errors (319)

•Latent Errors (100)

•Near Miss (95)

Approach to Improving Safety

•Quality Improvement Strategies (340)

•Legal and Policy Approaches (256)

•Error Reporting and Analysis (444)

•Communication Improvement (881)

•Human Factors Engineering (223)

•Teamwork (199)

•Specialization of Care (68)

•Logistical Approaches (99)

•Culture of Safety (186)

•Technologic Approaches (191)

•Education and Training (394)

Clinical Areas

•Allied Health Services (6)

Target Audience

•Health Care Providers (1112)

•Health Care Executives and Administrators (970)

•Non-Health Care Professionals (501)

•Patients (618)

Setting of Care

•Hospitals (1098)

•Psychiatric Facilities (5)

•Residential Facilities (21)

•Ambulatory Care (149)

•Outpatient Surgery (27)

•Patient Transport (8)

1 - 20 of 1648

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NEWSPAPER/MAGAZINE ARTICLE

Hospital tells of surgery on wrong side.

Smith S. Boston Globe. July 4, 2008;Metro section:1A.

STUDY

Variation in surgical time-out and site marking within pediatric otolaryngology.

Shah RK, Arjmand E, Roberson DW, Deutsch E, Derkay C. Arch Otolaryngol Head Neck Surg. 2011;137:69-73.

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

Medical mistakes unhappy reality.

Young A. The Atlanta Journal-Constitution. May 3, 2009:B1.

STUDY

Operating room briefings and wrong-site surgery.

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

NEWSPAPER/MAGAZINE ARTICLE

Third wrong-sided brain surgery at R.I. hospital.

Associated Press. MSNBC. November 27, 2007.

FACT SHEET/FAQS

What is Correct-Site Surgery?

American College of Surgeons.

NEWSPAPER/MAGAZINE ARTICLE

Wrong body part, wrong patient surgeries continue despite new procedures.

Rojas-Burke J. The Oregonian. May 25, 2011.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

NEWSPAPER/MAGAZINE ARTICLE

The pain of wrong site surgery.

Boodman SG. Washington Post. June 21, 2011:E1.

NEWSPAPER/MAGAZINE ARTICLE

Surgeon operates on wrong knee at Miriam Hospital.

Freyer FJ. Providence Journal. September 20, 2008.

NEWSPAPER/MAGAZINE ARTICLE

How to avoid falling victim to a hospital mistake.

Cohen E. Empowered Patient. CNN.com. November 13, 2009.

NEWSPAPER/MAGAZINE ARTICLE

Most surgery in wrong spot done on spine: 11 such cases found in state since 2006.

Smith S. Boston Globe. July 30, 2008;Metro section:1A.

NEWSPAPER/MAGAZINE ARTICLE

Medical culture about errors may be changing.

Gulliver D. Herald Tribune. September 3, 2007.

COMMENTARY classic

A 62-year-old woman with skin cancer who experienced wrong-site surgery.

Gallagher TH. JAMA. 2009;302:669-677.

NEWSPAPER/MAGAZINE ARTICLE

Another wrong-site surgery at RI Hospital.

Freyer FJ. Providence Journal. October 24, 2009.

MEASUREMENT TOOL/INDICATOR

AORN Evaluation of the Universal Protocol.

Association of PeriOperative Registered Nurses.

NEWSPAPER/MAGAZINE ARTICLE

'Wrong site' surgeries on the rise.

Davis R. USA Today. April 17, 2006.

STUDY

Wrong-site sinus surgery in otolaryngology.

Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.

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