AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (75)

•Diagnostic Errors (87)

•Identification Errors (131)

•Discontinuities, Gaps, and Hand-Off Problems (126)

•Fatigue and Sleep Deprivation (29)

•Medication Safety (364)

•Medical Complications (130)

•Nonsurgical Procedural Complications (33)

•Surgical Complications (503)

•Transfusion Complications (7)

•Psychological and Social Complications (70)

Origin/Sponsor

•Asia (5)

•Australia and New Zealand (9)

•Europe (38)

•North America (1328)

Resource Types

•Audiovisual (65)

•Award (7)

•Book/Report (67)

•Clinical Guideline (5)

•Journal Article (700)

•Legislation/Regulation (16)

•Meeting/Conference (3)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (417)

•Press Release/Announcement (4)

•Special or Theme Issue (8)

•Tools/Toolkit (34)

•Web Resource (58)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (261)

•Active Errors (562)

•Latent Errors (116)

•Near Miss (34)

Approach to Improving Safety

•Quality Improvement Strategies (278)

•Legal and Policy Approaches (239)

•Error Reporting and Analysis (374)

•Communication Improvement (428)

•Human Factors Engineering (252)

•Teamwork (107)

•Specialization of Care (52)

•Logistical Approaches (80)

•Culture of Safety (124)

•Technologic Approaches (205)

•Education and Training (299)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (933)

•Health Care Executives and Administrators (817)

•Non-Health Care Professionals (408)

•Patients (599)

Setting of Care

•Hospitals (961)

•Psychiatric Facilities (4)

•Residential Facilities (13)

•Ambulatory Care (116)

•Outpatient Surgery (30)

•Patient Transport (11)

1 - 20 of 1389

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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

Another wrong-site surgery at RI Hospital.

Freyer FJ. Providence Journal. October 24, 2009.

NEWSPAPER/MAGAZINE ARTICLE

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

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

NEWSPAPER/MAGAZINE ARTICLE

Medical mistakes unhappy reality.

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

NEWSPAPER/MAGAZINE ARTICLE

The pain of wrong site surgery.

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

REVIEW

Avoiding wrong site surgery: a systematic review.

DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.

STUDY

Wrong-site craniotomy: analysis of 35 cases and systems for prevention.

Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473.

COMMENTARY

Surgical site verification: A through Z.

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

NEWSPAPER/MAGAZINE ARTICLE

'Wrong-site' surgical mistakes are rare, preventable.

Stein L. St. Petersburg Times. June 21, 2010.

ORGANIZATIONAL POLICY/GUIDELINES classic

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

The Joint Commission.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

COMMENTARY classic

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

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

REVIEW

Spinal surgery and patient safety: a systems approach.

Wong DA. J Am Acad Orthop Surg. 2006;14:226-232.

COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

STUDY

Process changes to increase compliance with the Universal Protocol for bedside procedures.

Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.

STUDY

Medical errors in orthopaedics. Results of an AAOS member survey.

Wong DA, Herndon JH, Canale ST, et al. J Bone Joint Surg Am. 2009;91:547-557.

NEWSPAPER/MAGAZINE ARTICLE

The wrong foot, and other tales of surgical error.

Altman LK. New York Times. December 11, 2001;1:1.

STUDY

Wrong-site sinus surgery in otolaryngology.

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

NEWSPAPER/MAGAZINE ARTICLE

How to avoid falling victim to a hospital mistake.

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

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.

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