AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (94)

•Diagnostic Errors (112)

•Identification Errors (87)

•Discontinuities, Gaps, and Hand-Off Problems (267)

•Fatigue and Sleep Deprivation (38)

•Medication Safety (519)

•Medical Complications (278)

•Nonsurgical Procedural Complications (66)

•Surgical Complications (615)

•Transfusion Complications (11)

•Psychological and Social Complications (108)

Origin/Sponsor

•Africa (4)

•Asia (37)

•Australia and New Zealand (89)

•Central and South America (6)

•Europe (402)

•North America (1509)

Resource Types

•Audiovisual (4)

•Award (9)

•Book/Report (88)

•Clinical Guideline (6)

•Journal Article (1707)

•Legislation/Regulation (31)

•Meeting/Conference (15)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (107)

•Press Release/Announcement (13)

•Special or Theme Issue (42)

•Tools/Toolkit (24)

•Web Resource (51)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (509)

•Active Errors (451)

•Latent Errors (146)

•Near Miss (47)

Approach to Improving Safety

•Quality Improvement Strategies (528)

•Legal and Policy Approaches (133)

•Error Reporting and Analysis (481)

•Communication Improvement (770)

•Human Factors Engineering (371)

•Teamwork (382)

•Specialization of Care (145)

•Logistical Approaches (131)

•Culture of Safety (304)

•Technologic Approaches (314)

•Education and Training (489)

Clinical Areas

•Allied Health Services (9)

Target Audience
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Health Care Providers

•Allied Health Professionals (2)

•Clinical Technologists (7)

Setting of Care

•Psychiatric Facilities (9)

•Residential Facilities (37)

•Ambulatory Care (168)

•Outpatient Surgery (36)

•Patient Transport (20)

1 - 20 of 2105

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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.

REVIEW

Human factors in surgery: from Three Mile Island to the operating room.

D'Addessi A, Bongiovanni L, Volpe A, Pinto F, Bassi P. Urol Int. 2009;83:249-257.

STUDY

Interruptions and miscommunications in surgery: an observational study.

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

STUDY

Causes of near misses: perceptions of perioperative nurses.

Cohoon B. AORN J. 2011;93:551-565.

STUDY

The impact of organisational and individual factors on team communication in surgery: a qualitative study.

Gillespie BM, Chaboyer W, Longbottom P, Wallis M. Int J Nurs Stud. 2010;47:732-741.

REVIEW

Noise in the operating room—what do we know? A review of the literature.

Hasfeldt D, Laerkner E, Birkelund R. J Perianesth Nurs. 2010;25:380-386.

COMMENTARY

Reducing surgical complications.

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

REVIEW

Patient safety in surgery: non-technical aspects of safe surgical performance.

Youngson GG, Flin R. Patient Saf Surg. 2010;4:4.

STUDY

Use of briefings and debriefings as a tool in improving team work, efficiency, and communication in the operating theatre.

Bethune R, Sasirekha G, Sahu A, Cawthorn S, Pullyblank A. Postgrad Med J. 2011;87:331-334.

REVIEW

Surgical fires, a clear and present danger.

Yardley IE, Donaldson LJ. Surgeon. 2010;8:87-92.

STUDY

Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme.

Neily J, Mills PD, Lee P, et al. Qual Saf Health Care. 2010;19:360-364.

COMMENTARY

Communication in the perioperative setting.

Cvetic E. AORN J. 2011;94:261-270.

REVIEW

Enhancing communication in surgery through team training interventions: a systematic literature review.

Gillespie BM, Chaboyer W, Murray P. AORN J. 2010;92:642-657.

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

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.

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

Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.

Steinberger DM, Douglas SV, Kirschbaum MS. Prog Transplant. 2009;19:208-215.

COMMENTARY

The normalization of deviance: what are the perioperative risks?

McNamara SA. AORN J. 2011;93:796-801.

STUDY

Wubben I, van Manen JG, van den Akker BJ, Vaartjes SR, van Harten WH. Qual Saf Health Care. 2010;19:e64.

STUDY

Nature and timing of incidents intercepted by the SURPASS checklist in surgical patients.

de Vries EN, Prins HA, Bennink MC, et al. BMJ Qual Saf. 2012;21:503-508.

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