AHRQ Patient Safety Network

The Collection > Nurses

PATIENT SAFETY PRIMERS
Nursing and Patient Safety

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Safety Target

•Device-related Complications (40)

•Diagnostic Errors (8)

•Identification Errors (26)

•Discontinuities, Gaps, and Hand-Off Problems (89)

•Fatigue and Sleep Deprivation (16)

•Medication Safety (289)

•Medical Complications (68)

•Nonsurgical Procedural Complications (14)

•Surgical Complications (103)

•Transfusion Complications (2)

•Psychological and Social Complications (18)

Origin/Sponsor

•Asia (9)

•Australia and New Zealand (14)

•Central and South America (1)

Resource Types

•Clinical Guideline (5)

•Journal Article (640)

•Legislation/Regulation (14)

•Meeting/Conference (2)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (64)

•Press Release/Announcement (8)

•Special or Theme Issue (11)

•Tools/Toolkit (15)

•Web Resource (11)

Error Types

•Epidemiology of Errors and Adverse Events (119)

•Active Errors (97)

•Latent Errors (44)

•Near Miss (16)

Approach to Improving Safety

•Quality Improvement Strategies (213)

•Legal and Policy Approaches (30)

•Error Reporting and Analysis (163)

•Communication Improvement (194)

•Human Factors Engineering (101)

•Teamwork (87)

•Specialization of Care (41)

•Logistical Approaches (86)

•Culture of Safety (102)

•Technologic Approaches (112)

•Education and Training (149)

Clinical Areas

•Allied Health Services (2)

•Medicine (448)

•Nursing (395)

•Pharmacy (67)

Target Audience
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Nurses

Setting of Care

•Hospitals (501)

•Psychiatric Facilities (3)

•Residential Facilities (13)

•Ambulatory Care (35)

•Outpatient Surgery (4)

•Patient Transport (2)

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NEWSPAPER/MAGAZINE ARTICLE

'Wrong site' surgeries on the rise.

Davis R. USA Today. April 17, 2006.

COMMENTARY

Surgical site verification: A through Z.

Dunn D. J Perianesth Nurs. 2006;21:317-328.

ORGANIZATIONAL POLICY/GUIDELINES classic

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.

The Joint Commission.

NEWSPAPER/MAGAZINE ARTICLE

When surgery goes wrong: weighing up the risks.

Feinmann J. The Independent. November 14, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Tomorrow's operating room to harness Net, RFID.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Bringing surgeons down to earth.

Landro L. Wall Street Journal (Eastern edition). November 16, 2005:D1.

NEWSPAPER/MAGAZINE ARTICLE

M.R.I.'s strong magnets cited in accidents.

McNeil DG Jr. New York Times. August 19, 2005;National Desk section:1.

NEWSPAPER/MAGAZINE ARTICLE

New practices reduce childbirth risks.

Landro L. Wall Street Journal. July 12, 2006:D1. [Reprinted on Post-gazette.com].

STUDY

Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.

Hu YY, Arriaga AF, Roth EM, et al. Ann Surg. 2012;256:203-210.

STUDY

Error, stress, and teamwork in medicine and aviation: cross sectional surveys.

Sexton JB, Thomas EJ, Helmreich RL. BMJ. 2000;320:745-749.

NEWSPAPER/MAGAZINE ARTICLE

Accuracy at every step: the challenge of medication reconciliation.

Institute for Healthcare Improvement Web site. March 20, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Lights. Camera. Robot Action!

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

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.

REVIEW

Spinal surgery and patient safety: a systems approach.

Wong DA. J Am Acad Orthop Surg. 2006;14:226-232.

NEWSPAPER/MAGAZINE ARTICLE

The consumer: and now, a warning about labels.

Franklin D. New York Times. October 25, 2005:F1.

NEWSPAPER/MAGAZINE ARTICLE

Nurse is charged in death of patient.

Wahlberg D, Treleven E. Wisconsin State Journal. November 3, 2006:A1.

STUDY

Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work.

Nemeth C, O’Connor M, Klock PA, Cook R. Org Stud. 2006;27:1011-1035.

COMMENTARY

The evolution of the apology.

Newfield JS. Home Health Care Manage Pract. 2007;19:137-139.

STUDY

Patient misidentification in the neonatal intensive care unit: quantification of risk.

Gray JE, Suresh G, Ursprung R, et al. Pediatrics. 2006;117:e43-e47.

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