AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (44)

•Diagnostic Errors (40)

•Identification Errors (90)

•Discontinuities, Gaps, and Hand-Off Problems (95)

•Fatigue and Sleep Deprivation (29)

•Medication Safety (167)

•Medical Complications (105)

•Nonsurgical Procedural Complications (14)

•Surgical Complications (719)

•Transfusion Complications (4)

•Psychological and Social Complications (57)

Origin/Sponsor

•Africa (3)

•Asia (11)

•Australia and New Zealand (26)

•Central and South America (1)

Resource Types

•Clinical Guideline (4)

•Journal Article (709)

•Legislation/Regulation (16)

•Meeting/Conference (2)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (174)

•Press Release/Announcement (6)

•Special or Theme Issue (12)

•Tools/Toolkit (36)

•Web Resource (42)

Error Types

•Epidemiology of Errors and Adverse Events (209)

•Active Errors (213)

•Latent Errors (75)

•Near Miss (20)

Approach to Improving Safety

•Quality Improvement Strategies (260)

•Legal and Policy Approaches (101)

•Error Reporting and Analysis (273)

•Communication Improvement (462)

•Human Factors Engineering (243)

•Teamwork (145)

•Specialization of Care (34)

•Logistical Approaches (57)

•Culture of Safety (110)

•Technologic Approaches (93)

•Education and Training (357)

Clinical Areas

Target Audience

•Health Care Providers (756)

•Health Care Executives and Administrators (667)

•Non-Health Care Professionals (305)

•Patients (307)

Setting of Care

•Hospitals (869)

•Residential Facilities (2)

•Ambulatory Care (59)

•Outpatient Surgery (34)

•Patient Transport (3)

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STUDY

Implementing a pre-operative checklist to increase patient safety: a 1-year follow-up of personnel attitudes.

Nilsson L, Lindberget O, Gupta A, Vegfors M. Acta Anaesthesiol Scand. 2010;54:176-182.

COMMENTARY

Surgical site verification: A through Z.

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

FACT SHEET/FAQS

Having Surgery? What You Need to Know.

Rockville, MD: Agency for Healthcare Research and Quality; 2005. AHRQ Publication No. 05(06)-0074.

STUDY

Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR.

Lingard L, Espin S, Rubin B, et al. Qual Saf Health Care. 2005;14:340-346.

FACT SHEET/FAQS

Ensuring Correct Surgery.

Ann Arbor, MI: VA National Center for Patient Safety; 2006.

STUDY

The implementation of a perioperative checklist increases patients' perioperative safety and staff satisfaction.

Böhmer AB, Wappler F, Tinschmann T, et al. Acta Anaesthesiol Scand. 2012;56:332-338.

MULTI-USE WEBSITE

Hydraulic Fluid Facts.

Duke University Health System.

STUDY

A surgical safety checklist to reduce morbidity and mortality in a global population.

Haynes AB, Weiser TG, Berry WR, et al; for the Safe Surgery Saves Lives Study Group. N Engl J Med. 2009;360:491-499.

STUDY

Improving operating room safety.

Hurlbert SN, Garrett J. Patient Saf Surg. 2009;3:25.

STUDY

Safe surgery: how accurate are we at predicting intra-operative blood loss?

Solon JG, Egan C, McNamara DA. J Eval Clin Pract. 2013;19:100-105.

MULTI-USE WEBSITE

Safe Surgery Saves Lives.

Canadian Patient Safety Institute.

BOOK/REPORT

Better: A Surgeon's Notes on Performance.

Gawande A. New York, NY: Metropolitan Books; 2007. ISBN: 0805082115.

NEWSPAPER/MAGAZINE ARTICLE

A towel with a safety message.

Lerner M. Minneapolis Star Tribune. January 25, 2009:B1.

COMMENTARY

Engineering the system of communication for safer surgery.

Healey AN, Nagpal K, Moorthy K, Vincent CA. Cogn Tech Work. 2011;13:1-10.

NEWSPAPER/MAGAZINE ARTICLE

Medical mistakes unhappy reality.

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

AUDIOVISUAL

Limiting medical mistakes.

Maminta J. News 8 WTNH. February 3, 2012.

NEWSPAPER/MAGAZINE ARTICLE

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

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

REVIEW

Patient safety during anaesthesia: incorporation of the WHO safe surgery guidelines into clinical practice.

Schlack WS, Boermeester MA. Curr Opin Anaesthesiol. 2010;23:754-758.

ORGANIZATIONAL POLICY/GUIDELINES classic

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

The Joint Commission.

STUDY

Effects of an educational patient safety campaign on patients' safety behaviours and adverse events.

Schwappach DLB, Frank O, Buschmann U, Babst R. J Eval Clin Pract. 2013;19:285-291.

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