AHRQ Patient Safety Network

The Collection > General Hospitals

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Safety Target

•Device-related Complications (73)

•Diagnostic Errors (50)

•Identification Errors (91)

•Discontinuities, Gaps, and Hand-Off Problems (162)

•Fatigue and Sleep Deprivation (35)

•Medication Safety (341)

•Medical Complications (177)

•Nonsurgical Procedural Complications (44)

•Surgical Complications (503)

•Transfusion Complications (4)

•Psychological and Social Complications (63)

Origin/Sponsor

•Africa (2)

•Asia (28)

•Australia and New Zealand (59)

•Central and South America (6)

Resource Types

•Clinical Guideline (2)

•Journal Article (1203)

•Legislation/Regulation (10)

•Meeting/Conference (2)

•Newspaper/Magazine Article (81)

•Press Release/Announcement (4)

•Special or Theme Issue (19)

•Tools/Toolkit (6)

•Web Resource (15)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (485)

•Active Errors (316)

•Latent Errors (74)

•Near Miss (35)

Approach to Improving Safety

•Quality Improvement Strategies (312)

•Legal and Policy Approaches (65)

•Error Reporting and Analysis (351)

•Communication Improvement (397)

•Human Factors Engineering (276)

•Teamwork (239)

•Specialization of Care (99)

•Logistical Approaches (105)

•Culture of Safety (172)

•Technologic Approaches (210)

•Education and Training (338)

Clinical Areas

•Allied Health Services (2)

•Medicine (1250)

•Nursing (140)

•Pharmacy (86)

Target Audience

•Health Care Providers (1032)

•Health Care Executives and Administrators (1166)

•Non-Health Care Professionals (538)

•Patients (60)

Setting of Care
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General Hospitals

•Intensive Care Units (216)

•Emergency Departments (164)

•Operating Room (546)

•Labor and Delivery (72)

1 - 20 of 1373

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STUDY

Incorrect surgical procedures within and outside of the operating room.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

COMMENTARY

Inadvertent Castration.

Calland JF. AHRQ WebM&M [serial online]. January 2004.

STUDY

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

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

Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme.

Neily J, Mills PD, Lee P, et al. Qual Saf Health Care. 2010;19:360-364.

STUDY

Association between implementation of a medical team training program and surgical mortality.

Neily J, Mills PD, Young-Xu Y, et al. JAMA. 2010;304:1693-1700.

STUDY

Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.

Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.

STUDY

Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training Program improves the cardiopulmonary resuscitation code process.

Percarpio KB, Harris FS, Hatfield BA, et al. Jt Comm J Qual Patient Saf. 2010;36:424-429:AP1.

COMMENTARY

Surgical team training: promoting high reliability with nontechnical skills.

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

STUDY

Use of the Safety Attitudes Questionnaire as a measure in patient safety improvement.

Watts BV, Percarpio K, West P, Mills PD. J Patient Saf. 2010;6:206-209.

STUDY

Uncomfortable prescribing decisions in hospitals: the impact of teamwork.

Lewis PJ, Tully MP. J R Soc Med. 2009;102:481-488.

STUDY

Application of human error theory in case analysis of wrong procedures.

Duthie EA. J Patient Saf. 2010;6:108-114.

REVIEW

Avoiding wrong site surgery: a systematic review.

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

NEWSPAPER/MAGAZINE ARTICLE

Beyond the count: preventing the retention of foreign objects.

PA-PSRS Patient Saf Advis. June 2009;6:39-45.

REVIEW

Enhancing communication in surgery through team training interventions: a systematic literature review.

Gillespie BM, Chaboyer W, Murray P. AORN J. 2010;92:642-657.

STUDY

Communication failure in the operating room.

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

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

The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases.

Wolf FA, Way LW, Stewart L. Ann Surg. 2010;252:477-485.

REVIEW

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.

STUDY

Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units.

Mayer CM, Cluff L, Lin WT, et al. Jt Comm J Qual Patient Saf. 2011;37:365-374.

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