AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (138)

•Diagnostic Errors (150)

•Identification Errors (106)

•Discontinuities, Gaps, and Hand-Off Problems (356)

•Fatigue and Sleep Deprivation (80)

•Medication Safety (902)

•Medical Complications (362)

•Nonsurgical Procedural Complications (92)

•Surgical Complications (617)

•Transfusion Complications (13)

•Psychological and Social Complications (120)

Origin/Sponsor

•Africa (3)

•Asia (31)

•Australia and New Zealand (71)

•Central and South America (6)

•Europe (319)

•North America (2764)

Resource Types

•Clinical Guideline (8)

•Journal Article (2364)

•Legislation/Regulation (56)

•Meeting/Conference (26)

•Newsletter/Journal (12)

•Newspaper/Magazine Article (281)

•Press Release/Announcement (22)

•Special or Theme Issue (62)

•Tools/Toolkit (51)

•Web Resource (100)

•Grant (7)

Error Types

•Epidemiology of Errors and Adverse Events (712)

•Active Errors (529)

•Latent Errors (184)

•Near Miss (58)

Approach to Improving Safety

•Quality Improvement Strategies (776)

•Legal and Policy Approaches (272)

•Error Reporting and Analysis (783)

•Communication Improvement (882)

•Human Factors Engineering (467)

•Teamwork (401)

•Specialization of Care (221)

•Logistical Approaches (218)

•Culture of Safety (399)

•Technologic Approaches (512)

•Education and Training (650)

Clinical Areas

•Allied Health Services (9)

Target Audience
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Health Care Providers

•Allied Health Professionals (4)

•Clinical Technologists (21)

Setting of Care

•Psychiatric Facilities (12)

•Residential Facilities (54)

•Ambulatory Care (290)

•Outpatient Surgery (44)

•Patient Transport (28)

1 - 20 of 3225

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STUDY

Impact of preoperative briefings on operating room delays.

Nundy S, Mukherjee A, Sexton JB, et al. Arch Surg. 2008;143:1068-1072.

STUDY

Improved operating room teamwork via SAFETY prep: a rural community hospital's experience.

Paige JT, Aaron DL, Yang T, Howell DS, Chauvin SW. World J Surg. 2009;33:1181-1187.

STUDY

Cardiac surgery errors: results from the UK National Reporting and Learning System.

Martinez EA, Shore A, Colantuoni E, et al. Int J Qual Health Care. 2011;23:151-158.

STUDY

A surgical safety checklist to reduce morbidity and mortality in a global population.

Haynes AB, Weiser TG, Berry WR, et al; for the Safe Surgery Saves Lives Study Group. N Engl J Med. 2009;360:491-499.

COMMENTARY

Executive summary of the American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting: reinvigorating safety in office-based gynecologic surgery.

Erickson TB, Kirkpatrick DH, DeFrancesco MS, Lawrence HC III. Obstet Gynecol. 2010;115:147-151.

STUDY

Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention.

Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. BMJ Qual Saf. 2011;20:102-107.

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.

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 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.

STUDY

Improving operating room safety.

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

STUDY

Interruptions and miscommunications in surgery: an observational study.

Gillespie BM, Chaboyer W, Fairweather N. AORN J. 2012;95:576-590.

STUDY

A novel method for reproducibly measuring the effects of interventions to improve emotional climate, indices of team skills and communication, and threat to patient outcome in a high-volume thoracic surgery center.

Nurok M, Lipsitz S, Satwicz P, Kelly A, Frankel A. Arch Surg. 2010;145:489-495.

STUDY

Infrequent physician use of implantable cardioverter-defibrillators risks patient safety.

Lyman S, Sedrakyan A, Do H, Razzano R, Mushlin AI. Heart. 2011;97:1655-1660.

STUDY

Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety.

Einav Y, Gopher D, Kara I, et al. Chest. 2010;137:443-449.

COMMENTARY

Implementing a pediatric surgical safety checklist in the OR and beyond.

Norton EK, Rangel SJ. AORN J. 2010;92:61-71.

REVIEW

Determining the state of knowledge for implementing the Universal Protocol recommendations: an integrative review of the literature.

Conrardy JA, Brenek B, Myers S. AORN J. 2010;92:194-207.

COMMENTARY

Reducing surgical complications.

Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:660-665.

STUDY

A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes.

Schraagen JM, Schouten T, Smit M, et al. BMJ Qual Saf. 2011;20:599-603.

STUDY

ProvenCare: quality improvement model for designing highly reliable care in cardiac surgery.

Berry SA, Doll MC, McKinley KE, Casale AS, Bothe A Jr. Qual Saf Health Care. 2009;18:360-368.

STUDY

Can aviation-based team training elicit sustainable behavioral change?

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

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