AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (147)

•Diagnostic Errors (180)

•Identification Errors (113)

•Discontinuities, Gaps, and Hand-Off Problems (419)

•Fatigue and Sleep Deprivation (84)

•Medication Safety (974)

•Medical Complications (403)

•Nonsurgical Procedural Complications (97)

•Surgical Complications (647)

•Transfusion Complications (13)

•Psychological and Social Complications (135)

Origin/Sponsor

•Africa (4)

•Asia (37)

•Australia and New Zealand (80)

•Central and South America (7)

•Europe (381)

•North America (2979)

Resource Types

•Clinical Guideline (10)

•Journal Article (2605)

•Legislation/Regulation (57)

•Meeting/Conference (27)

•Newsletter/Journal (12)

•Newspaper/Magazine Article (304)

•Press Release/Announcement (24)

•Special or Theme Issue (71)

•Tools/Toolkit (54)

•Web Resource (118)

•Grant (7)

Error Types

•Epidemiology of Errors and Adverse Events (770)

•Active Errors (588)

•Latent Errors (220)

•Near Miss (68)

Approach to Improving Safety

•Quality Improvement Strategies (930)

•Legal and Policy Approaches (304)

•Error Reporting and Analysis (872)

•Communication Improvement (1046)

•Human Factors Engineering (496)

•Teamwork (418)

•Specialization of Care (237)

•Logistical Approaches (241)

•Culture of Safety (450)

•Technologic Approaches (562)

•Education and Training (734)

Clinical Areas

•Allied Health Services (11)

Target Audience
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Health Care Providers

•Allied Health Professionals (6)

•Clinical Technologists (25)

Setting of Care

•Psychiatric Facilities (12)

•Residential Facilities (59)

•Ambulatory Care (330)

•Outpatient Surgery (49)

•Patient Transport (30)

1 - 20 of 3545

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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

Implementing standardized operating room briefings and debriefings at a large regional medical center.

Berenholtz SM, Schumacher K, Hayanga AJ, et al. Jt Comm J Qual Patient Saf. 2009;35:391-397.

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.

STUDY

Impact of preoperative briefings on operating room delays.

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

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.

COMMENTARY

Retained surgical items and minimally invasive surgery.

Gibbs VC. World J Surg. 2011;35:1532-1539.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

Bernhard B. The Orange County Register. April 19, 2006.

MULTI-USE WEBSITE

Council on Surgical and Perioperative Safety.

Council on Surgical and Perioperative Safety; 633 N. St. Clair St. Chicago, IL, 60611.

STUDY

Communication failure in the operating room.

Halverson AL, Casey JT, Andersson J, et al. Surgery. 2011;49:305-310.

STUDY

A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative.

Arriaga AF, Elbardissi AW, Regenbogen SE, et al. Ann Surg. 2011;253:849-854.

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.

REVIEW

Surgical fires, a clear and present danger.

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

COMMENTARY

Video technology to advance safety in the operating room and perioperative environment.

Xiao Y, Schimpff S, Mackenzie C, et al. Surg Innov. 2007;14:52-61.

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.

STUDY

Discrepant perceptions of communication, teamwork and situation awareness among surgical team members.

Wauben LS, Dekker-van Doorn CM, van Wijngaarden JD, et al. Int J Qual Health Care. 2011;23:159-166.

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.

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.

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