AHRQ Patient Safety Network

The Collection > Health Care Executives and Administrators

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Safety Target

•Device-related Complications (112)

•Diagnostic Errors (91)

•Identification Errors (97)

•Discontinuities, Gaps, and Hand-Off Problems (274)

•Fatigue and Sleep Deprivation (108)

•Medication Safety (611)

•Medical Complications (260)

•Nonsurgical Procedural Complications (36)

•Surgical Complications (520)

•Transfusion Complications (11)

•Psychological and Social Complications (116)

Origin/Sponsor

•Africa (1)

•Asia (10)

•Australia and New Zealand (33)

•Central and South America (1)

•Europe (172)

•North America (2517)

Resource Types

•Clinical Guideline (1)

•Journal Article (1965)

•Legislation/Regulation (39)

•Meeting/Conference (19)

•Newsletter/Journal (8)

•Newspaper/Magazine Article (332)

•Press Release/Announcement (18)

•Special or Theme Issue (49)

•Tools/Toolkit (33)

•Web Resource (64)

•Grant (6)

Error Types

•Epidemiology of Errors and Adverse Events (484)

•Active Errors (277)

•Latent Errors (157)

•Near Miss (46)

Approach to Improving Safety

•Quality Improvement Strategies (740)

•Legal and Policy Approaches (345)

•Error Reporting and Analysis (771)

•Communication Improvement (632)

•Human Factors Engineering (348)

•Teamwork (275)

•Specialization of Care (180)

•Logistical Approaches (243)

•Culture of Safety (497)

•Technologic Approaches (416)

•Education and Training (520)

Clinical Areas

•Allied Health Services (6)

•Medicine (1730)

•Nursing (403)

•Pharmacy (187)

Target Audience
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Health Care Executives and Administrators

•Facility and Group Administrators (186)

•Nurse Managers (410)

•Risk Managers (293)

•Quality and Safety Professionals (763)

Setting of Care

•Hospitals (1768)

•Psychiatric Facilities (8)

•Residential Facilities (38)

•Ambulatory Care (137)

•Outpatient Surgery (36)

•Patient Transport (8)

1 - 20 of 2762

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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.

STUDY

Operating room briefings and wrong-site surgery.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Wrong-site surgery.

Butcher L. Hosp Health Netw. November 2011.

MEASUREMENT TOOL/INDICATOR

AORN Evaluation of the Universal Protocol.

Association of PeriOperative Registered Nurses.

NEWSPAPER/MAGAZINE ARTICLE

Bringing surgeons down to earth.

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

STUDY

Incidence, patterns, and prevention of wrong-site surgery.

Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.

STUDY

Expanded surgical time out: a key to real-time data collection and quality improvement.

Altpeter T, Luckhardt K, Lewis JN, Harken AH, Polk HC Jr. J Am Coll Surg. 2007;204:527-532.

NEWSPAPER/MAGAZINE ARTICLE

Tomorrow's operating room to harness Net, RFID.

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

NEWSPAPER/MAGAZINE ARTICLE

When surgery goes wrong: weighing up the risks.

Feinmann J. The Independent. November 14, 2006.

COMMENTARY

Wrong site surgery.

Fraser SG, Adams W. Br J Ophthalmol. 2006;90:814-816.

NEWSPAPER/MAGAZINE ARTICLE

Reused devices, surgery's deadly suspects.

Klein A. The Washington Post. December 30, 2005:A3.

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.

NEWSPAPER/MAGAZINE ARTICLE

Surgical errors: new products, protocols help slash the risks.

Williamson JE. Healthcare Purchasing News. January 2006;30:22-25.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

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

Doctor removes ovaries from wrong patient.

Bramson K, Mooney T. Providence Journal. August 18, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Lights. Camera. Robot Action!

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

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