AHRQ Patient Safety Network

The Collection > Operating Room

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Safety Target

•Device-related Complications (13)

•Diagnostic Errors (6)

•Identification Errors (33)

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

•Fatigue and Sleep Deprivation (12)

•Medication Safety (29)

•Medical Complications (19)

•Nonsurgical Procedural Complications (2)

•Surgical Complications (303)

•Transfusion Complications (2)

•Psychological and Social Complications (37)

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•Asia (3)

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Resource Types

•Book/Report (6)

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•Newspaper/Magazine Article (23)

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Error Types

•Epidemiology of Errors and Adverse Events (95)

•Active Errors (85)

•Latent Errors (29)

•Near Miss (8)

Approach to Improving Safety

•Quality Improvement Strategies (68)

•Legal and Policy Approaches (27)

•Error Reporting and Analysis (75)

•Communication Improvement (137)

•Human Factors Engineering (112)

•Teamwork (75)

•Specialization of Care (13)

•Logistical Approaches (24)

•Culture of Safety (42)

•Technologic Approaches (32)

•Education and Training (90)

Clinical Areas

•Medicine (361)

•Nursing (22)

•Pharmacy (5)

Target Audience

•Health Care Providers (340)

•Health Care Executives and Administrators (293)

•Non-Health Care Professionals (135)

•Patients (14)

Setting of Care
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Operating Room

1 - 20 of 367

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NEWSPAPER/MAGAZINE ARTICLE

A hospital races to learn lessons of Ferrari pit stop.

Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].

STUDY

Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality.

Catchpole KR, de Leval MR, McEwan A, et al. Paediatr Anaesth. 2007;17:470-478.

NEWSPAPER/MAGAZINE ARTICLE

Healthcare industry representatives: maximizing benefits and reducing risks.

PA-PSRS Patient Saf Advis. March 2006;3:13-19.

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.

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.

STUDY

Burns surgery handover study: trainees' assessment of current practice in the British Isles.

Al-Benna S, Al-Ajam Y, Alzoubaidi D. Burns. 2009;35:509-512.

STUDY

Surgical case listing accuracy: failure analysis at a high-volume academic medical center.

Cima RR, Hale C, Kollengode A, Rogers JC, Cassivi SD, Deschamps C. Arch Surg. 2010;145:641-646.

COMMENTARY

Ruptured Heterotopic Pregnancy.

Cedars MI. AHRQ WebM&M [serial online]. January 2004.

COMMENTARY

The top 10 list for a safe and effective sign-out.

Kemp CD, Bath JM, Berger J, et al. Arch Surg. 2008;143:1008-1010.

COMMENTARY

DNR in the OR and Afterwards

Lo B. AHRQ WebM&M [serial online]. September 2006.

COMMENTARY

Inadvertent Castration.

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

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

Postoperative handover: problems, pitfalls, and prevention of error.

Nagpal K, Arora S, Abboudi M, et al. Ann Surg. 2010;252:171-176.

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.

STUDY

Handover after pediatric heart surgery: a simple tool improves information exchange.

Zavalkoff SR, Razack SI, Lavoie J, Dancea AB. Pediatr Crit Care Med. 2011;12:309-313.

STUDY

Framing family conversation after early diagnosis of iatrogenic injury and incidental findings.

Barrios L, Tsuda S, Derevianko A, et al. Surg Endosc. 2009;23:2535-2542.

COMMENTARY

Counting for patient safety.

Watson DS. AORN J. 2006;84:273-275.

NEWSPAPER/MAGAZINE ARTICLE

The day Joy died.

Brandeland GP. Med Econ. 2006 Oct 20;83:50, 52-53.

REVIEW

Teamwork and patient safety in dynamic domains of healthcare: a review of the literature.

Manser T. Acta Anaesthesiol Scand. 2009;53:143-151.

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.

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