AHRQ Patient Safety Network

The Collection > Operating Room

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Safety Target

•Device-related Complications (16)

•Diagnostic Errors (6)

•Identification Errors (41)

•Discontinuities, Gaps, and Hand-Off Problems (34)

•Fatigue and Sleep Deprivation (20)

•Medication Safety (28)

•Medical Complications (16)

•Nonsurgical Procedural Complications (4)

•Surgical Complications (505)

•Transfusion Complications (1)

•Psychological and Social Complications (28)

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•Asia (8)

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•Clinical Guideline (2)

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•Newspaper/Magazine Article (39)

•Special or Theme Issue (9)

•Tools/Toolkit (5)

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Error Types

•Epidemiology of Errors and Adverse Events (163)

•Active Errors (90)

•Latent Errors (31)

•Near Miss (11)

Approach to Improving Safety

•Quality Improvement Strategies (107)

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•Error Reporting and Analysis (133)

•Communication Improvement (165)

•Human Factors Engineering (137)

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•Education and Training (137)

Clinical Areas

•Medicine (546)

•Nursing (40)

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Target Audience

•Health Care Providers (443)

•Health Care Executives and Administrators (401)

•Non-Health Care Professionals (174)

•Patients (39)

Setting of Care
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Operating Room

1 - 20 of 554

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STUDY

Surgeon age and operative mortality in the United States.

Waljee JF, Greenfield LJ, Dimick JB, Birkmeyer JD. Ann Surg. 2006;244:353-362.

STUDY

Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study.

van Klei WA, Hoff RG, van Aarnhem EE, et al. Ann Surg. 2012;255:44-49.

REVIEW

Fatal errors in nitrous oxide delivery.

Herff H, Paal P, von Goedecke A, Lindner KH, Keller C, Wenzel V. Anaesthesia. 2007;62:1202-1206.

STUDY

Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program.

Kiran RP, Ahmed Ali U, Coffey JC, Vogel JD, Pokala N, Fazio VW. Ann Surg. 2012;256:469-475.

STUDY

Adverse events detected by clinical surveillance on an obstetric service.

Forster AJ, Fung I, Caughey S, et al. Obstet Gynecol. 2006;108:1073-1083.

STUDY

Surgical skill is predicted by the ability to detect errors.

Bann S, Khan M, Datta V, Darzi A. Am J Surg. 2005;189:412-415.

COMMENTARY

The lost sponge: patient safety in the operating room.

Grant-Orser A, Davies P, Singh SS. CMAJ. 2012;184:1275-1278.

STUDY

Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003.

Cook RI, Wreathall J, Smith A, et al. Transplantation. 2007;84:1602-1609.

STUDY

Risk factors in patient safety: minimally invasive surgery versus conventional surgery.

Rodrigues SP, Wever AM, Dankelman J, Jansen FW. Surg Endosc. 2012;26:350-356.

STUDY

Quantitative analysis of adverse events in neurosurgery.

Houkin K, Baba T, Minamida Y, Nonaka T, Koyanagi I, Iiboshi S. Neurosurgery. 2009;65:587-594.

STUDY

Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols.

Rampersaud YR, Moro ER, Neary MA, et al. Spine. 2006;31:1503-1510.

STUDY

When the bone flap hits the floor.

Jankowitz BT, Kondziolka DS. Neurosurgery. 2006;59:585-590.

STUDY

Does surgeon fatigue influence outcomes after anterior resection for rectal cancer?

Schieman C, MacLean AR, Buie WD, Rudmik LR, Ghali WA, Dixon E. Am J Surg. 2008;195:684-687; discussion 687-688.

STUDY

Harvey Cushing's open and thorough documentation of surgical mishaps at the dawn of neurologic surgery.

Latimer K, Pendleton C, Olivi A, Cohen-Gadol AA, Brem H, Quiñones-Hinojosa A. Arch Surg. 2011;146:226-232.

BOOK/REPORT

Medmarx Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005.

Rockville, MD: United States Pharmacopeia; 2007.

STUDY

Safe surgery: how accurate are we at predicting intra-operative blood loss?

Solon JG, Egan C, McNamara DA. J Eval Clin Pract. 2013;19:100-105.

REVIEW

How strong is the evidence for the use of perioperative beta blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials.

Devereaux PJ, Beattie WS, Choi PT, et al. BMJ. 2005;331:313-321.

STUDY

Waking up the next morning: surgeons' emotional reactions to adverse events.

Luu S, Patel P, St-Martin L, et al. Med Educ. 2012;46:1179-1188.

STUDY

Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR.

Lingard L, Espin S, Rubin B, et al. Qual Saf Health Care. 2005;14:340-346.

STUDY

Surgical confusions in ophthalmology.

Simon JW, Ngo Y, Khan S, Strogatz D. Arch Ophthalmol. 2007;125:1515-1522.

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