AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (126)

•Diagnostic Errors (143)

•Identification Errors (104)

•Discontinuities, Gaps, and Hand-Off Problems (283)

•Fatigue and Sleep Deprivation (45)

•Medication Safety (735)

•Medical Complications (338)

•Nonsurgical Procedural Complications (82)

•Surgical Complications (728)

•Transfusion Complications (15)

•Psychological and Social Complications (75)

Origin/Sponsor

•Africa (7)

•Asia (59)

•Australia and New Zealand (237)

•Central and South America (11)

•Europe (509)

•North America (1716)

Resource Types

•Clinical Guideline (6)

•Journal Article (2149)

•Legislation/Regulation (35)

•Meeting/Conference (10)

•Newsletter/Journal (5)

•Newspaper/Magazine Article (116)

•Press Release/Announcement (13)

•Special or Theme Issue (33)

•Tools/Toolkit (17)

•Web Resource (59)

•Grant (6)

Error Types

•Epidemiology of Errors and Adverse Events (1174)

•Active Errors (484)

•Latent Errors (138)

•Near Miss (57)

Approach to Improving Safety

•Quality Improvement Strategies (577)

•Legal and Policy Approaches (142)

•Error Reporting and Analysis (766)

•Communication Improvement (638)

•Human Factors Engineering (410)

•Teamwork (280)

•Specialization of Care (162)

•Logistical Approaches (139)

•Culture of Safety (265)

•Technologic Approaches (389)

•Education and Training (553)

Clinical Areas

•Allied Health Services (9)

Target Audience

•Health Care Providers (2119)

•Health Care Executives and Administrators (2203)

•Non-Health Care Professionals (871)

•Patients (110)

Setting of Care

•Hospitals (1838)

•Psychiatric Facilities (9)

•Residential Facilities (41)

•Ambulatory Care (205)

•Outpatient Surgery (45)

•Patient Transport (30)

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STUDY

The impact of trained assistance on error rates in anaesthesia: a simulation-based randomised controlled trial.

Weller JM, Merry AF, Robinson BJ, Warman GR, Janssen A. Anaesthesia. 2009;64:126-130.

STUDY

Barriers to adverse event and error reporting in anesthesia.

Heard GC, Sanderson PM, Thomas RD. Anesth Analg. 2012;114:604-614.

STUDY

Multimodal system designed to reduce errors in recording and administration of drugs in anaesthesia: prospective randomised clinical evaluation.

Merry AF, Webster CS, Hannam J, et al. BMJ. 2011;343:d5543.

STUDY

Surgeon's vigilance in the operating room.

Zheng B, Tien G, Atkins SM, et al. Am J Surg. 2011;201:667-671.

STUDY

Optimising surgical training: use of feedback to reduce errors during a simulated surgical procedure.

Boyle E, Al-Akash M, Gallagher AG, Traynor O, Hill AD, Neary PC. Postgrad Med J. 2011;87:524-528.

COMMENTARY

What happens when things go wrong?

Brandom BW, Callahan P, Micalizzi DA. Paediatr Anaesth. 2011;21:730-736.

STUDY

Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.

Vermaire D, Caruso MC, Lesko A, et al. BMJ Qual Saf. 2011;20:895-902.

COMMENTARY

The contribution of labelling to safe medication administration in anaesthetic practice.

Merry AF, Shipp DH, Lowinger JS. Best Pract Res Clin Anaesthesiol. 2011;25:145-159.

STUDY

Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008.

Cassidy CJ, Smith A, Arnot-Smith J. Anaesthesia. 2011;66:879-888.

STUDY

Why isn't 'time out' being implemented? An exploratory study.

Gillespie BM, Chaboyer W, Wallis M, Fenwick C. Qual Saf Health Care. 2010;19:103-106.

COMMENTARY

Vial Mistakes Involving Heparin.

Vanderveen T. AHRQ WebM&M [serial online]. May 2009.

STUDY

What is the safety of nonemergent operative procedures performed at night?

Turrentine FE, Wang H, Young JS, Calland JF. J Trauma. 2010;69:313-319.

STUDY

Representative case series from public hospital admissions 1998 II: surgical adverse events.

Briant R, Morton J, Lay-Yee R, Davis P, Ali W. N Z Med J. 2005;118:U1591.

STUDY

Critical phase distractions in anaesthesia and the sterile cockpit concept.

Broom MA, Capek AL, Carachi P, Akeroyd MA, Hilditch G. Anaesthesia. 2011;66:175-179.

STUDY

Interruptions and blood transfusion checks: lessons from the simulated operating room.

Liu D, Grundgeiger T, Sanderson PM, Jenkins SA, Leane TA. Anesth Analg. 2009;108:219-222.

STUDY

Communication failure in the operating room.

Halverson AL, Casey JT, Andersson J, et al. Surgery. 2011;49:305-310.

STUDY

Information needs in operating room teams: what is right, what is wrong, and what is needed?

Wong HW, Forrest D, Healey A, et al. Surg Endosc. 2011;25:1913-1920.

STUDY

Infrequent physician use of implantable cardioverter-defibrillators risks patient safety.

Lyman S, Sedrakyan A, Do H, Razzano R, Mushlin AI. Heart. 2011;97:1655-1660.

STUDY

Safety on an inpatient pediatric otolaryngology service: many small errors, few adverse events.

Shah RK, Lander L, Forbes P, Jenkins K, Healy GB, Roberson DW. Laryngoscope. 2009;119:871-879.

STUDY

A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative.

Arriaga AF, Elbardissi AW, Regenbogen SE, et al. Ann Surg. 2011;253:849-854.

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