AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (34)

•Diagnostic Errors (64)

•Identification Errors (26)

•Discontinuities, Gaps, and Hand-Off Problems (108)

•Fatigue and Sleep Deprivation (53)

•Medication Safety (213)

•Medical Complications (33)

•Nonsurgical Procedural Complications (15)

•Surgical Complications (228)

•Transfusion Complications (2)

•Psychological and Social Complications (37)

Origin/Sponsor

•Asia (14)

•Australia and New Zealand (21)

•Central and South America (1)

Resource Types

•Clinical Guideline (6)

•Journal Article (694)

•Legislation/Regulation (14)

•Meeting/Conference (3)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (84)

•Press Release/Announcement (8)

•Special or Theme Issue (10)

•Tools/Toolkit (12)

•Web Resource (18)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (152)

•Active Errors (129)

•Latent Errors (43)

•Near Miss (14)

Approach to Improving Safety

•Quality Improvement Strategies (224)

•Legal and Policy Approaches (57)

•Error Reporting and Analysis (225)

•Communication Improvement (237)

•Human Factors Engineering (92)

•Teamwork (90)

•Specialization of Care (39)

•Logistical Approaches (76)

•Culture of Safety (81)

•Technologic Approaches (105)

•Education and Training (253)

Clinical Areas

•Allied Health Services (2)

Target Audience
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Physicians

Setting of Care

•Hospitals (535)

•Psychiatric Facilities (1)

•Residential Facilities (1)

•Ambulatory Care (40)

•Outpatient Surgery (12)

•Patient Transport (2)

1 - 20 of 881

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STUDY

Surgical crisis management skills training and assessment: a stimulation-based approach to enhancing operating room performance.

Moorthy K, Munz Y, Forrest D, et al. Ann Surg. 2006;244:139-147.

COMMENTARY

A common body of care: the ethics and politics of teamwork in the operating theater are inseparable.

Bleakley A. J Med Philos. 2006;31:305-322.

STUDY

Attitudes to teamwork and safety in the operating theatre.

Flin R, Yule S, McKenzie L, Paterson-Brown S, Maran N. Surgeon. June 2006;4:145-151.

STUDY

Observational assessment of surgical teamwork: a feasibility study.

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

NEWSPAPER/MAGAZINE ARTICLE

Costly issues of an uncommunicative OR.

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

NEWSPAPER/MAGAZINE ARTICLE

When surgery goes wrong: weighing up the risks.

Feinmann J. The Independent. November 14, 2006.

STUDY

Teamwork in the operating theatre: cohesion or confusion?

Undre S, Sevdalis N, Healey AN, Darzi A, Vincent CA. J Eval Clin Pract. 2006;12:182-189.

COMMENTARY

A theory-based instrument to evaluate team communication in the operating room: balancing measurement authenticity and reliability.

Lingard L, Regehr G, Espin S, Whyte S. Qual Saf Health Care. 2006;15:422-426.

STUDY

Reliability of a revised NOTECHS scale for use in surgical teams.

Sevdalis N, Davis R, Koutantji M, et al. Am J Surg. 2008;196:184-190.

STUDY

A human factors analysis of technical and team skills among surgical trainees during procedural simulations in a simulated operating theatre.

Moorthy K, Munz Y, Adams S, Pandey V, Darzi A. Ann Surg. 2005;242:631-639.

COMMENTARY

How to avoid the 'seven deadly sins of surgery.'

Kirby R, Challacombe B, Dasgupta P, Fitzpatrick JM. BJU Int. 2012;109:171-173.

NEWSPAPER/MAGAZINE ARTICLE

Lights. Camera. Robot Action!

Shute N. U.S. News & World Report. January 23, 2006;140:62-63.

NEWSPAPER/MAGAZINE ARTICLE

Tomorrow's operating room to harness Net, RFID.

Olsen S. CNET News.com; October 19, 2005.

STUDY

Perceptions of patient safety culture among physicians and RNs in the perioperative area.

Scherer D, Fitzpatrick JJ. AORN J. 2008;87:163-175.

STUDY

Potential errors and their prevention in operating room teamwork as experienced by Finnish, British and American nurses.

Silén-Lipponen M, Tossavainen K, Turunen H, Smith A. Int J Nurs Pract. 2005;11:21-32.

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.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion #464: patient safety in the surgical environment.

ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2010;116:786-790.

STUDY

Mapping changes in surgical mortality over 9 years by peer review audit.

Thompson AM, Ashraf Z, Burton H, Stonebridge PA. Br J Surg. 2005;92:1449-1452.

STUDY

From the flight deck to the operating room: an initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation.

Paige J, Kozmenko V, Morgan B, et al. J Surg Educ. 2007;64:369-377.

STUDY

Simulation-based training improves physicians' performance in patient care in high-stakes clinical setting of cardiac surgery.

Bruppacher HR, Alam SK, LeBlanc VR, et al. Anesthesiology. 2010;112:985-992.

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