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 (25)

•Discontinuities, Gaps, and Hand-Off Problems (63)

•Fatigue and Sleep Deprivation (4)

•Medication Safety (223)

•Medical Complications (40)

•Nonsurgical Procedural Complications (11)

•Surgical Complications (100)

•Transfusion Complications (2)

•Psychological and Social Complications (15)

Origin/Sponsor

•Asia (12)

•Australia and New Zealand (21)

•Central and South America (1)

Resource Types

•Clinical Guideline (4)

•Journal Article (437)

•Legislation/Regulation (11)

•Meeting/Conference (2)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (58)

•Press Release/Announcement (7)

•Special or Theme Issue (7)

•Tools/Toolkit (14)

•Web Resource (10)

Error Types

•Epidemiology of Errors and Adverse Events (87)

•Active Errors (82)

•Latent Errors (37)

•Near Miss (11)

Approach to Improving Safety

•Quality Improvement Strategies (169)

•Legal and Policy Approaches (20)

•Error Reporting and Analysis (120)

•Communication Improvement (183)

•Human Factors Engineering (112)

•Teamwork (78)

•Specialization of Care (22)

•Logistical Approaches (43)

•Culture of Safety (67)

•Technologic Approaches (79)

•Education and Training (120)

Clinical Areas

•Allied Health Services (2)

•Medicine (364)

•Nursing (207)

•Pharmacy (48)

Target Audience
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Nurses

Setting of Care

•Hospitals (348)

•Psychiatric Facilities (6)

•Residential Facilities (9)

•Ambulatory Care (26)

•Outpatient Surgery (3)

•Patient Transport (4)

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NEWSPAPER/MAGAZINE ARTICLE

When surgery goes wrong: weighing up the risks.

Feinmann J. The Independent. November 14, 2006.

COMMENTARY

Defining the technical skills of teamwork in surgery.

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

STUDY

Failures in communication and information transfer across the surgical care pathway: interview study.

Nagpal K, Arora S, Vats A, et al. BMJ Qual Saf. 2012;21:843-849.

NEWSPAPER/MAGAZINE ARTICLE

Lights. Camera. Robot Action!

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

COMMENTARY

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

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Tomorrow's operating room to harness Net, RFID.

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

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.

MULTI-USE WEBSITE

Scottish Audit of Surgical Mortality.

Royal College of Physicians and Surgeons of Glasgow, 232-242 St Vincent Street, Glasgow, UK G2 5RJ.

NEWSPAPER/MAGAZINE ARTICLE

Costly issues of an uncommunicative OR.

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

ORGANIZATIONAL POLICY/GUIDELINES classic

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

The Joint Commission.

STUDY

The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors in a UK intensive care unit.

Sanghera IS, Franklin BD, Dhillon S. Anaesthesia. 2007;62:53-61.

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

Incorrect surgical counts: a qualitative analysis.

Rowlands A, Steeves R. AORN J. 2010;92:410-419.

STUDY

The culture of a trauma team in relation to human factors.

Cole E, Crichton N. J Clin Nurs. 2006;15:1257-1266.

COMMENTARY

Surgical site verification: A through Z.

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

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.

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