AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (25)

•Diagnostic Errors (9)

•Identification Errors (68)

•Discontinuities, Gaps, and Hand-Off Problems (51)

•Fatigue and Sleep Deprivation (24)

•Medication Safety (42)

•Medical Complications (28)

•Nonsurgical Procedural Complications (6)

•Surgical Complications (581)

•Transfusion Complications (2)

•Psychological and Social Complications (38)

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•Audiovisual (6)

•Book/Report (11)

•Clinical Guideline (3)

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•Special or Theme Issue (11)

•Tools/Toolkit (10)

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Error Types

•Epidemiology of Errors and Adverse Events (161)

•Active Errors (141)

•Latent Errors (43)

•Near Miss (15)

Approach to Improving Safety

•Quality Improvement Strategies (141)

•Legal and Policy Approaches (45)

•Error Reporting and Analysis (156)

•Communication Improvement (211)

•Human Factors Engineering (171)

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Clinical Areas

•Medicine (677)

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Target Audience

•Health Care Providers (531)

•Health Care Executives and Administrators (494)

•Non-Health Care Professionals (210)

•Patients (59)

Setting of Care
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Operating Room

1 - 20 of 686

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REVIEW

Information transfer and communication in surgery: a systematic review.

Nagpal K, Vats A, Lamb B, et al. Ann Surg. 2010;252:225-239.

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

Preoperative surgical briefings do not delay operating room start times and are popular with surgical team members.

Ali M, Osborne A, Bethune R, Pullyblank A. J Patient Saf. 2011;7:138-142.

COMMENTARY

Wise before the event.

Watts G. BMJ. 2010;340:c1378.

STUDY

An evaluation of information transfer through the continuum of surgical care: a feasibility study.

Nagpal K, Vats A, Ahmed K, Vincent C, Moorthy K. Ann Surg. 2010;252:402-407.

COMMENTARY

Engineering the system of communication for safer surgery.

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

STUDY

Quality and safety on an acute surgical ward: an exploratory cohort study of process and outcome.

Kreckler S, Catchpole KR, New SJ, Handa A, McCulloch PG. Ann Surg. 2009;250:1035-1040.

STUDY

Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit.

McCulloch P, Kreckler S, New S, Sheena Y, Handa A, Catchpole K. BMJ. 2010;341:c5469.

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.

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

Perfusion safety: new initiatives and enduring principles.

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

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

Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients.

de Vries EN, Prins HA, Bennink MC, et al. BMJ Qual Saf. 2012;21:503-508.

STUDY

Improving operating room safety.

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

COMMENTARY

Cutting out human error.

Feinmann J. BMJ. 2008;337:a2370.

STUDY

Promoting patient safety through prospective risk identification: example from peri-operative care.

Smith A, Boult M, Woods I, Johnson S. Qual Saf Health Care. 2010;19:69-73.

STUDY

Crisis checklists for the operating room: development and pilot testing.

Ziewacz JE, Arriaga AF, Bader AM, et al. J Am Coll Surg. 2011;213:212-219.

ORGANIZATIONAL POLICY/GUIDELINES

EACTS guidelines for the use of patient safety checklists.

Clark SC, Dunning J, Alfieri OR, et al; Clinical Guidelines Committee of the European Association for Cardio-Thoracic Surgery. Eur J Cardiothorac Surg. 2012;41:993-1004.

REVIEW

Patient safety in surgery: non-technical aspects of safe surgical performance.

Youngson GG, Flin R. Patient Saf Surg. 2010;4:4.

STUDY

Use of briefings and debriefings as a tool in improving team work, efficiency, and communication in the operating theatre.

Bethune R, Sasirekha G, Sahu A, Cawthorn S, Pullyblank A. Postgrad Med J. 2011;87:331-334.

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