AHRQ Patient Safety Network

The Collection > Operating Room

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Safety Target

•Device-related Complications (18)

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•Identification Errors (72)

•Discontinuities, Gaps, and Hand-Off Problems (49)

•Fatigue and Sleep Deprivation (21)

•Medication Safety (36)

•Medical Complications (28)

•Nonsurgical Procedural Complications (6)

•Surgical Complications (547)

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•Epidemiology of Errors and Adverse Events (144)

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Approach to Improving Safety

•Quality Improvement Strategies (134)

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Clinical Areas

•Medicine (635)

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Target Audience

•Health Care Providers (496)

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•Non-Health Care Professionals (188)

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Setting of Care
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Operating Room

1 - 20 of 649

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STUDY

Surgical never events in the United States.

Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgery. 2013;153:465-472.

AUDIOVISUAL

Using the Targeted Solutions Tool for wrong site surgery: is your organization at risk?

Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; February 13, 2012.

STUDY

Surgical specimen identification errors: a new measure of quality in surgical care.

Makary MA, Epstein J, Pronovost PJ, Millman EA, Hartmann EC, Freischlag JA. Surgery. 2007;141:450-455.

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.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

STUDY

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

Sexton JB, Makary MA, Tersigni AR, et al. Anesthesiology. 2006;105:877-884.

COMMENTARY

Time out: an analysis.

Dillon KA. AORN J. 2008;88:437-442.

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.

COMMENTARY

Surgical site verification: A through Z.

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

ORGANIZATIONAL POLICY/GUIDELINES classic

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

The Joint Commission.

NEWSPAPER/MAGAZINE ARTICLE

'Wrong site' surgeries on the rise.

Davis R. USA Today. April 17, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Wrong-site surgery.

Butcher L. Hosp Health Netw. November 2011.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

NEWSPAPER/MAGAZINE ARTICLE

Hospital tells of surgery on wrong side.

Smith S. Boston Globe. July 4, 2008;Metro section:1A.

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.

COMMENTARY

Video technology to advance safety in the operating room and perioperative environment.

Xiao Y, Schimpff S, Mackenzie C, et al. Surg Innov. 2007;14:52-61.

STUDY

Surgical team behaviors and patient outcomes.

Mazzocco K, Petitti DB, Fong KT, et al. Am J Surg. 2009;197:678-685.

STUDY

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

Makary MA, Sexton JB, Freischlag JA, et al. J Am Coll Surg. 2006;202:746-752.

COMMENTARY

The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited.

Stahel PF, Mehler PS, Clarke TJ, Varnell J. Patient Saf Surg. 2009;3:14.

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