AHRQ Patient Safety Network

The Collection > Operating Room

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Safety Target

•Device-related Complications (24)

•Diagnostic Errors (9)

•Identification Errors (69)

•Discontinuities, Gaps, and Hand-Off Problems (52)

•Fatigue and Sleep Deprivation (21)

•Medication Safety (42)

•Medical Complications (29)

•Nonsurgical Procedural Complications (6)

•Surgical Complications (562)

•Transfusion Complications (2)

•Psychological and Social Complications (37)

Origin/Sponsor

•Asia (7)

•Australia and New Zealand (18)

Resource Types

•Clinical Guideline (3)

•Journal Article (527)

•Legislation/Regulation (13)

•Meeting/Conference (1)

•Newspaper/Magazine Article (71)

•Press Release/Announcement (1)

•Special or Theme Issue (10)

•Tools/Toolkit (10)

•Web Resource (17)

Error Types

•Epidemiology of Errors and Adverse Events (153)

•Active Errors (144)

•Latent Errors (40)

•Near Miss (15)

Approach to Improving Safety

•Quality Improvement Strategies (134)

•Legal and Policy Approaches (47)

•Error Reporting and Analysis (149)

•Communication Improvement (214)

•Human Factors Engineering (168)

•Teamwork (126)

•Specialization of Care (15)

•Logistical Approaches (36)

•Culture of Safety (71)

•Technologic Approaches (61)

•Education and Training (158)

Clinical Areas

•Medicine (658)

•Nursing (55)

•Pharmacy (4)

Target Audience

•Health Care Providers (523)

•Health Care Executives and Administrators (470)

•Non-Health Care Professionals (198)

•Patients (66)

Setting of Care
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Operating Room

1 - 20 of 669

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NEWSPAPER/MAGAZINE ARTICLE

Clinic sued over towel left in patient.

McCarty JF. Plain Dealer. January 16, 2007:A1.

NEWSPAPER/MAGAZINE ARTICLE

Doctor removes ovaries from wrong patient.

Bramson K, Mooney T. Providence Journal. August 18, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Fires during surgeries a bigger risk than thought.

Kowalczyk L. Boston Globe. November 7, 2007;Health/Science section:1A.

NEWSPAPER/MAGAZINE ARTICLE

Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.

Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

Bernhard B. The Orange County Register. April 19, 2006.

REVIEW

Detecting adverse events in dermatologic surgery.

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

FACT SHEET/FAQS

Speak Up: Help Avoid Mistakes in Your Surgery.

Oakbrook Terrace, IL: Joint Commission.

REVIEW

Can we make postoperative patient handovers safer? A systematic review of the literature.

Segall N, Bonifacio AS, Schroeder RA, et al; Durham VA Patient Safety Center of Inquiry. Anesth Analg. 2012;115:102-115.

CLINICAL GUIDELINE

A clinician's guide to surgical fires: how they occur, how to prevent them, how to put them out.

ECRI. Health Devices. 2003;32:5-24. NGC:002914.

COMMENTARY

Surgical team training: promoting high reliability with nontechnical skills.

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

NEWSPAPER/MAGAZINE ARTICLE

The pain of wrong site surgery.

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

STUDY

Can aviation-based team training elicit sustainable behavioral change?

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

STUDY

Perception of intimidation in a perioperative setting.

Dull DL, Fox L. Am J Med Qual. 2010;25:87-94.

COURSE MATERIAL/CURRICULUM

Patient Safety in the OR.

Denver, CO: Association of Perioperative Registered Nurses.

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.

NEWSPAPER/MAGAZINE ARTICLE

Preventing surgical errors.

Frenzel JC, Kelly T. HHN Magazine Online. January 6, 2009.

STUDY

Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs.

Petrovic MA, Aboumatar H, Baumgartner WA, et al. J Cardiothorac Vasc Anesth. 2012;26:11-16.

SPECIAL OR THEME ISSUE

Patient Safety.

Martin RF, Sanchez JA, eds. Surg Clin North Am. 2012;92:1-177.

STUDY

Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.

Kaplan LJ, Maerz LL, Schuster K, et al. J Trauma. 2009;67:173-179.

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.

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