AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (113)

•Diagnostic Errors (93)

•Identification Errors (122)

•Discontinuities, Gaps, and Hand-Off Problems (257)

•Fatigue and Sleep Deprivation (65)

•Medication Safety (593)

•Medical Complications (313)

•Nonsurgical Procedural Complications (66)

•Surgical Complications (823)

•Transfusion Complications (11)

•Psychological and Social Complications (91)

Origin/Sponsor

•Africa (2)

•Asia (17)

•Australia and New Zealand (35)

•Central and South America (1)

•Europe (213)

•North America (2261)

Resource Types

•Audiovisual (18)

•Award (9)

•Book/Report (91)

•Clinical Guideline (6)

•Journal Article (2005)

•Legislation/Regulation (35)

•Meeting/Conference (12)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (234)

•Press Release/Announcement (8)

•Special or Theme Issue (37)

•Tools/Toolkit (28)

•Web Resource (50)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (614)

•Active Errors (416)

•Latent Errors (140)

•Near Miss (50)

Approach to Improving Safety

•Quality Improvement Strategies (711)

•Legal and Policy Approaches (209)

•Error Reporting and Analysis (749)

•Communication Improvement (597)

•Human Factors Engineering (408)

•Teamwork (290)

•Specialization of Care (157)

•Logistical Approaches (200)

•Culture of Safety (334)

•Technologic Approaches (391)

•Education and Training (519)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (1735)

•Health Care Executives and Administrators (2210)

•Non-Health Care Professionals (927)

•Patients (163)

Setting of Care

•Hospitals (1825)

•Psychiatric Facilities (5)

•Residential Facilities (36)

•Ambulatory Care (142)

•Outpatient Surgery (51)

•Patient Transport (15)

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STUDY

Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes.

Antonacci AC, Lam S, Lavarias V, Homel P, Eavey RD. Arch Surg. 2008;143:1192-1197.

BOOK/REPORT

Annual Benchmarking Report: Malpractice Risks in Surgery.

Cambridge, MA: CRICO/RMF Strategies; 2010.

REVIEW

Detecting adverse events in dermatologic surgery.

Pinney D, Pearce DJ, Feldman SR. Dermatol Surg. 2010;36:8-14.

COMMENTARY

Instrument readiness: an important link to patient safety.

McNamara SA. AORN J. 2011;93:160-164.

COMMENTARY

Surgical team training: promoting high reliability with nontechnical skills.

Paige JT. Surg Clin North Am. 2010;90:569-581.

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

Can aviation-based team training elicit sustainable behavioral change?

Sax HC, Browne P, Mayewski RJ, et al. Arch Surg. 2009;144:1133-1137.

NEWSPAPER/MAGAZINE ARTICLE

Error reduction through team leadership: applying aviation's CRM model in the OR.

Healy GB, Barker J, Madonna G. Bull Amer Coll Surg. February 2006;91:10-15.

STUDY

ProvenCare: quality improvement model for designing highly reliable care in cardiac surgery.

Berry SA, Doll MC, McKinley KE, Casale AS, Bothe A Jr. Qual Saf Health Care. 2009;18:360-368.

COMMENTARY classic

Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand.

Ring DC, Herndon JH, Meyer GS. N Engl J Med. 2010;363:1950-1957.

ORGANIZATIONAL POLICY/GUIDELINES

Recommendations for quality assurance and improvement in surgical and autopsy pathology.

Association of Directors of Anatomic and Surgical Pathology. Hum Pathol. 2006;37:985-988.

STUDY

Determinants of adverse events in vascular surgery.

Hernandez-Boussard T, McDonald KM, Morton JM, Dalman RL, Bech FR. J Am Coll Surg. 2012;214:788-797.

NEWSPAPER/MAGAZINE ARTICLE

5 sure-fire methods: complying with NPSG.03.04.01.

Joint Commission: The Source. January 2012;10:5-6.

STUDY

The relationship of the emotional climate of work and threat to patient outcome in a high-volume thoracic surgery operating room team.

Nurok M, Evans LA, Lipsitz S, Satwicz P, Kelly A, Frankel A. BMJ Qual Saf. 2011;20:237-242.

STUDY

Effective surgical safety checklist implementation.

Conley DM, Singer SJ, Edmondson L, Berry WR, Gawande AA. J Am Coll Surg. 2011;212:873-879.

COMMENTARY

Improving operating room and perioperative safety: background and specific recommendations.

Schimpff SC. Surg Innov. 2007;14:127-135.

STUDY

Applicability of Healthcare Failure Mode and Effects Analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments.

Linkin DR, Sausman C, Santos L, et al. Clin Infect Dis. 2005;41:1014-1019.

COMMENTARY

Perfusion safety: new initiatives and enduring principles.

Kurusz M. Perfusion. 2011;26(suppl 1):6-14.

STUDY

Burnout and medical errors among American surgeons.

Shanafelt TD, Balch CM, Bechamps G, et al. Ann Surg. 2010;251:995-1000.

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