AHRQ Patient Safety Network

The Collection > Physicians

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Safety Target

•Device-related Complications (42)

•Diagnostic Errors (138)

•Identification Errors (33)

•Discontinuities, Gaps, and Hand-Off Problems (149)

•Fatigue and Sleep Deprivation (74)

•Medication Safety (348)

•Medical Complications (49)

•Nonsurgical Procedural Complications (23)

•Surgical Complications (228)

•Transfusion Complications (3)

•Psychological and Social Complications (63)

Origin/Sponsor

•Asia (17)

•Australia and New Zealand (25)

•Central and South America (1)

•Europe (140)

•North America (1033)

Resource Types

•Audiovisual (13)

•Book/Report (26)

•Clinical Guideline (7)

•Journal Article (1015)

•Legislation/Regulation (17)

•Meeting/Conference (3)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (132)

•Press Release/Announcement (10)

•Special or Theme Issue (11)

•Tools/Toolkit (17)

•Web Resource (20)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (248)

•Active Errors (194)

•Latent Errors (60)

•Near Miss (17)

Approach to Improving Safety

•Quality Improvement Strategies (306)

•Legal and Policy Approaches (103)

•Error Reporting and Analysis (357)

•Communication Improvement (304)

•Human Factors Engineering (110)

•Teamwork (89)

•Specialization of Care (52)

•Logistical Approaches (110)

•Culture of Safety (92)

•Technologic Approaches (202)

•Education and Training (274)

Clinical Areas

•Allied Health Services (3)

Target Audience
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Physicians

Setting of Care

•Hospitals (667)

•Psychiatric Facilities (2)

•Residential Facilities (7)

•Ambulatory Care (105)

•Outpatient Surgery (14)

•Patient Transport (3)

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COMMENTARY

Right? Left? Neither!

Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.

STUDY

Governing the surgical count through communication interactions: implications for patient safety.

Riley R, Manias E, Polglase A. Qual Saf Health Care. 2006;15:369-374.

STUDY

Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?

Seiden SC, Barach P. Arch Surg. 2006;141:931-939.

STUDY

Observational assessment of surgical teamwork: a feasibility study.

Undre S, Healey AN, Darzi A, Vincent CA. World J Surg. 2006;30:1774-1783.

COMMENTARY

A nurse-led approach to developing and implementing a collaborative count policy.

Norton EK, Micheli AJ, Gedney J, Felkerson TM. AORN J. 2012;95:222-227.

STUDY

Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology.

Macario A, Morris D, Morris S. Arch Surg. 2006;141:659-662.

REVIEW

Communication devices in the operating room.

Ruskin KJ. Curr Opin Anaesthesiol. 2006;19:655-659.

MULTI-USE WEBSITE

Surgical Care Improvement Project.

National SCIP Partnership, Oklahoma Foundation for Medical Quality, 14000 Quail Springs Parkway, Suite 400, Oklahoma City, OK, 73134.

NEWSPAPER/MAGAZINE ARTICLE

Costly issues of an uncommunicative OR.

Neil R. Mat Manage Health Care. March 2006;15:30-33.

STUDY

Operating room briefings and wrong-site surgery.

Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.

NEWSPAPER/MAGAZINE ARTICLE

Safety in ASCs: putting patients first.

Dix K. Today's Surgicenter. December 1, 2006.

STUDY

Retained surgical items: a problem yet to be solved.

Stawicki SP, Moffatt-Bruce SD, Ahmed HM, et al. J Am Coll Surg. 2013;216:15-22.

STUDY

Effectiveness of a radiofrequency detection system as an adjunct to manual counting protocols for tracking surgical sponges: a prospective trial of 2,285 patients.

Rupp CC, Kagarise MJ, Nelson SM, et al. J Am Coll Surg. 2012;215:524-533.

COMMENTARY

Surgical count practice variability and the potential for retained surgical items.

Edel EM. AORN J. 2012;95:228-238.

STUDY

Bridging the communication gap in the operating room with medical team training.

Awad SS, Fagan SP, Bellows C, et al. Am J Surg. 2005;190:770-774.

REVIEW

The role of practice guidelines and evidence-based medicine in perioperative patient safety.

Crosby E. Can J Anaesth. 2013;60:143-151.

STUDY

Representative case series from public hospital admissions 1998 II: surgical adverse events.

Briant R, Morton J, Lay-Yee R, Davis P, Ali W. N Z Med J. 2005;118:U1591.

NEWSPAPER/MAGAZINE ARTICLE

Follow-up tips for a safe, efficient practice.

Weiss GG. Med Econ. May 19, 2006; 83:47-49.

FACT SHEET/FAQS

Medication safety issue brief. Bar code implementation strategies.

American Hospital Association, American Society of Health-System Pharmacists, Hospitals and Health Networks. Hosp Health Netw. July 2005;79:65-66.

STUDY

Thirty-day outcomes support implementation of a surgical safety checklist.

Bliss LA, Ross-Richardson CB, Sanzari LJ, et al. J Am Coll Surg. 2012;215:766-776.

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