AHRQ Patient Safety Network

The Collection > Nurses

PATIENT SAFETY PRIMERS
Nursing and Patient Safety

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Safety Target

•Device-related Complications (36)

•Diagnostic Errors (8)

•Identification Errors (23)

•Discontinuities, Gaps, and Hand-Off Problems (68)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (202)

•Medical Complications (25)

•Nonsurgical Procedural Complications (7)

•Surgical Complications (99)

•Transfusion Complications (2)

•Psychological and Social Complications (11)

Origin/Sponsor

•Asia (12)

•Australia and New Zealand (14)

•Central and South America (2)

Resource Types

•Clinical Guideline (4)

•Journal Article (382)

•Legislation/Regulation (11)

•Meeting/Conference (3)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (53)

•Press Release/Announcement (7)

•Special or Theme Issue (3)

•Tools/Toolkit (14)

•Web Resource (10)

Error Types

•Epidemiology of Errors and Adverse Events (66)

•Active Errors (78)

•Latent Errors (36)

•Near Miss (11)

Approach to Improving Safety

•Quality Improvement Strategies (159)

•Legal and Policy Approaches (17)

•Error Reporting and Analysis (106)

•Communication Improvement (178)

•Human Factors Engineering (76)

•Teamwork (72)

•Specialization of Care (18)

•Logistical Approaches (32)

•Culture of Safety (59)

•Technologic Approaches (82)

•Education and Training (98)

Clinical Areas

•Allied Health Services (2)

•Medicine (333)

•Nursing (154)

•Pharmacy (50)

Target Audience
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Nurses

Setting of Care

•Hospitals (308)

•Psychiatric Facilities (2)

•Residential Facilities (7)

•Ambulatory Care (24)

•Outpatient Surgery (3)

•Patient Transport (4)

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COMMENTARY

Right? Left? Neither!

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

COMMENTARY

On O.R. Off?

Leonard M. AHRQ WebM&M [serial online]. March 2005.

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.

STUDY

Changes in prognosis after the first postoperative complication.

Silber JH, Rosenbaum PR, Trudeau ME, et al. Med Care. 2005;43:122-131.

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

Communication failures in the operating room: an observational classification of recurrent types and effects.

Lingard L, Espin S, Whyte S, et al. Qual Saf Health Care. 2004;13:330-334.

COMMENTARY

DNR in the OR and Afterwards

Lo B. AHRQ WebM&M [serial online]. September 2006.

COMMENTARY

Operating room briefings.

Makary MA, Holzmueller CG, Sexton BJ, et al. Jt Comm J Qual Patient Saf. 2006;32:407-410.

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

The struggle to improve patient care in the face of professional boundaries.

Powell AE, Davies HT. Soc Sci Med. 2012;75:807-814.

COMMENTARY

Defining the technical skills of teamwork in surgery.

Healey AN, Undre S, Vincent CA. Qual Saf Health Care. 2006;15:231-234.

COMMENTARY

Hold the tPA.

Fagan SC. AHRQ WebM&M [serial online]. April 2005.

NEWSPAPER/MAGAZINE ARTICLE

Tomorrow's operating room to harness Net, RFID.

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

ORGANIZATIONAL POLICY/GUIDELINES

Statement on the prevention of retained foreign bodies after surgery.

Bulletin of the American College of Surgeons; October 2005.

COMMENTARY

Hidden Mystery.

Brunette DD. AHRQ WebM&M [serial online]. March 2005.

COMMENTARY

Thin Air.

Gaba DM. AHRQ WebM&M [serial online]. October 2004.

COMMENTARY

Surprise Wire

Pearl JM, Donaldson NE. AHRQ WebM&M [serial online]. July/August 2005.

STUDY

Risk factors associated with incorrect surgical counts.

Rowlands A. AORN J. 2012;96:272-284.

CLINICAL GUIDELINE

Practice Advisory on Intraoperative Awareness and Brain Function Monitoring.

ASA Task Force on Intraoperative Awareness and Brain Function Monitoring. Park Ridge, IL: American Society of Anesthesiologists; July 2005.

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.

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