AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (157)

•Diagnostic Errors (229)

•Identification Errors (125)

•Discontinuities, Gaps, and Hand-Off Problems (407)

•Fatigue and Sleep Deprivation (87)

•Medication Safety (1118)

•Medical Complications (395)

•Nonsurgical Procedural Complications (103)

•Surgical Complications (570)

•Transfusion Complications (18)

•Psychological and Social Complications (139)

Origin/Sponsor

•Africa (5)

•Asia (43)

•Australia and New Zealand (96)

•Central and South America (8)

•Europe (418)

•North America (3043)

Resource Types

•Clinical Guideline (9)

•Journal Article (2731)

•Legislation/Regulation (63)

•Meeting/Conference (29)

•Newsletter/Journal (13)

•Newspaper/Magazine Article (317)

•Press Release/Announcement (25)

•Special or Theme Issue (59)

•Tools/Toolkit (59)

•Web Resource (106)

•Grant (7)

Error Types

•Epidemiology of Errors and Adverse Events (1056)

•Active Errors (706)

•Latent Errors (232)

•Near Miss (76)

Approach to Improving Safety

•Quality Improvement Strategies (886)

•Legal and Policy Approaches (328)

•Error Reporting and Analysis (1018)

•Communication Improvement (970)

•Human Factors Engineering (535)

•Teamwork (307)

•Specialization of Care (243)

•Logistical Approaches (248)

•Culture of Safety (412)

•Technologic Approaches (593)

•Education and Training (720)

Clinical Areas

•Allied Health Services (10)

Target Audience
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Health Care Providers

•Allied Health Professionals (6)

•Clinical Technologists (38)

Setting of Care

•Psychiatric Facilities (13)

•Residential Facilities (66)

•Ambulatory Care (382)

•Outpatient Surgery (44)

•Patient Transport (32)

1 - 20 of 3671

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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.

COMMENTARY classic

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

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

STUDY

Safety on an inpatient pediatric otolaryngology service: many small errors, few adverse events.

Shah RK, Lander L, Forbes P, Jenkins K, Healy GB, Roberson DW. Laryngoscope. 2009;119:871-879.

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.

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

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

Variation in surgical time-out and site marking within pediatric otolaryngology.

Shah RK, Arjmand E, Roberson DW, Deutsch E, Derkay C. Arch Otolaryngol Head Neck Surg. 2011;137:69-73.

NEWSPAPER/MAGAZINE ARTICLE

Preventing wrong-site surgery in Minnesota: a 5-year journey.

Rydrych D, Apold J, Harder K. Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34.

STUDY

Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.

Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.

COMMENTARY

The Other Side.

Vincent C. AHRQ WebM&M [serial online]. October 2003.

STUDY

Transitioning between electronic health records: effects on ambulatory prescribing safety.

Abramson EL, Malhotra S, Fischer K, et al. J Gen Intern Med. 2011;26:868-874.

STUDY

ED overcrowding is associated with an increased frequency of medication errors.

Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. Am J Emerg Med. 2010;28:304-309.

STUDY

Resident participation does not affect surgical outcomes, despite introduction of new techniques.

Patel SP, Gauger PG, Brown DL, Englesbe MJ, Cederna PS. J Am Coll Surg. 2010;211:540-545.

STUDY

Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.

Vermaire D, Caruso MC, Lesko A, et al. BMJ Qual Saf. 2011;20:895-902.

STUDY

Evaluating an evidence-based bundle for preventing surgical site infection.

Anthony T, Murray BW, Sum-Ping JT, et al. Arch Surg. 2011;146:263-269.

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