AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (159)

•Diagnostic Errors (228)

•Identification Errors (124)

•Discontinuities, Gaps, and Hand-Off Problems (428)

•Fatigue and Sleep Deprivation (87)

•Medication Safety (1153)

•Medical Complications (392)

•Nonsurgical Procedural Complications (111)

•Surgical Complications (494)

•Transfusion Complications (16)

•Psychological and Social Complications (125)

Origin/Sponsor

•Africa (4)

•Asia (50)

•Australia and New Zealand (97)

•Central and South America (7)

•Europe (383)

•North America (3018)

Resource Types

•Clinical Guideline (9)

•Journal Article (2722)

•Legislation/Regulation (58)

•Meeting/Conference (27)

•Newsletter/Journal (13)

•Newspaper/Magazine Article (295)

•Press Release/Announcement (26)

•Special or Theme Issue (57)

•Tools/Toolkit (52)

•Web Resource (104)

•Grant (8)

Error Types

•Epidemiology of Errors and Adverse Events (1056)

•Active Errors (709)

•Latent Errors (241)

•Near Miss (74)

Approach to Improving Safety

•Quality Improvement Strategies (862)

•Legal and Policy Approaches (302)

•Error Reporting and Analysis (966)

•Communication Improvement (959)

•Human Factors Engineering (496)

•Teamwork (301)

•Specialization of Care (247)

•Logistical Approaches (265)

•Culture of Safety (420)

•Technologic Approaches (611)

•Education and Training (701)

Clinical Areas

•Allied Health Services (12)

•Complementary and Alternative Medicine (1)

Target Audience
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Health Care Providers

•Allied Health Professionals (5)

•Clinical Technologists (39)

Setting of Care

•Psychiatric Facilities (17)

•Residential Facilities (64)

•Ambulatory Care (427)

•Outpatient Surgery (47)

•Patient Transport (32)

1 - 20 of 3618

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STUDY

Process changes to increase compliance with the Universal Protocol for bedside procedures.

Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.

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.

STUDY

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

REVIEW

Avoiding wrong site surgery: a systematic review.

DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.

STUDY

Wrong-site craniotomy: analysis of 35 cases and systems for prevention.

Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473.

STUDY

Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.

Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.

STUDY

Incorrect surgical procedures within and outside of the operating room.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

STUDY

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.

STUDY

Impact of implementing alerts about medication black-box warnings in electronic health records.

Yu DT, Seger DL, Lasser KE, et al. Pharmacoepidemiol Drug Saf. 2011;20:192-202.

STUDY

Wrong-site sinus surgery in otolaryngology.

Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.

REVIEW

Patient safety in dermatology: a review of the literature.

Cao LY, Taylor JS, Vidimos A. Dermatol Online J. 2010;16:3.

BOOK/REPORT

Adverse Health Events in Minnesota: Ninth Annual Public Report.

St. Paul, MN: Minnesota Department of Health; January 2013.

COMMENTARY classic

A 62-year-old woman with skin cancer who experienced wrong-site surgery.

Gallagher TH. JAMA. 2009;302:669-677.

STUDY

Outcome of 6 years of protocol use for preventing wrong site office surgery.

Starling J 3rd, Coldiron BM. J Am Acad Dermatol. 2011;65:807-810.

STUDY

The role of advice in medication administration errors in the pediatric ambulatory setting.

Lemer C, Bates DW, Yoon C, Keohane C, Fitzmaurice G, Kaushal R. J Patient Saf. 2009;5:168-175.

STUDY

Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.

Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25:441-447.

STUDY

Eight-year experience with a neurosurgical checklist.

Lyons MK. Am J Med Qual. 2010;25:285-288.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals collaborate to prevent wrong-site surgery.

Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.

STUDY

Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after 1,946,831 operations in children.

Camp M, Chang DC, Zhang Y, Chrouser K, Colombani PM, Abdullah F. Arch Surg. 2010;145:1085-1090.

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