AHRQ Patient Safety Network

The Collection > Health Care Executives and Administrators

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Safety Target

•Device-related Complications (58)

•Diagnostic Errors (50)

•Identification Errors (66)

•Discontinuities, Gaps, and Hand-Off Problems (175)

•Fatigue and Sleep Deprivation (60)

•Medication Safety (334)

•Medical Complications (171)

•Nonsurgical Procedural Complications (25)

•Surgical Complications (554)

•Transfusion Complications (5)

•Psychological and Social Complications (186)

Origin/Sponsor

•Africa (1)

•Asia (30)

•Australia and New Zealand (65)

•Central and South America (1)

•Europe (509)

•North America (1181)

Resource Types

•Audiovisual (8)

•Award (5)

•Book/Report (128)

•Clinical Guideline (1)

•Journal Article (1427)

•Legislation/Regulation (21)

•Meeting/Conference (9)

•Newspaper/Magazine Article (138)

•Press Release/Announcement (7)

•Special or Theme Issue (44)

•Tools/Toolkit (26)

•Web Resource (32)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (345)

•Active Errors (195)

•Latent Errors (112)

•Near Miss (34)

Approach to Improving Safety

•Quality Improvement Strategies (529)

•Legal and Policy Approaches (181)

•Error Reporting and Analysis (590)

•Communication Improvement (500)

•Human Factors Engineering (269)

•Teamwork (394)

•Specialization of Care (100)

•Logistical Approaches (140)

•Culture of Safety (412)

•Technologic Approaches (214)

•Education and Training (398)

Clinical Areas

•Allied Health Services (6)

Target Audience
< All

Health Care Executives and Administrators

•Facility and Group Administrators (145)

•Nurse Managers (210)

•Risk Managers (215)

•Quality and Safety Professionals (660)

Setting of Care

•Hospitals (1249)

•Psychiatric Facilities (8)

•Residential Facilities (17)

•Ambulatory Care (77)

•Outpatient Surgery (33)

•Patient Transport (11)

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STUDY

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

Makary MA, Sexton JB, Freischlag JA, et al. J Am Coll Surg. 2006;202:746-752.

COMMENTARY

Defining the technical skills of teamwork in surgery.

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

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

When surgery goes wrong: weighing up the risks.

Feinmann J. The Independent. November 14, 2006.

STUDY

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

Sexton JB, Makary MA, Tersigni AR, et al. Anesthesiology. 2006;105:877-884.

REVIEW

The impact of stress on surgical performance: a systematic review of the literature.

Arora S, Sevdalis N, Nestel D, Woloshynowych M, Darzi A, Kneebone R. Surgery. 2010;147:318-330, 330.e1-6.

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.

STUDY

Development of a rating system for surgeons' non-technical skills.

Yule S, Flin R, Paterson-Brown S, Maran N, Rowley D. Med Educ. 2006;40:1098-1104.

COMMENTARY

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

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

STUDY

The effects of stress and coping on surgical performance during simulations.

Wetzel CM, Black SA, Hanna GB, et al. Ann Surg. 2010;251:171-176.

SPECIAL OR THEME ISSUE

2009 Doctor-Nurse Behavior Survey.

Physician Exec. Nov-Dec 2009;5-22.

COMMENTARY

Right? Left? Neither!

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

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

Causes of near misses: perceptions of perioperative nurses.

Cohoon B. AORN J. 2011;93:551-565.

NEWSPAPER/MAGAZINE ARTICLE

Lights. Camera. Robot Action!

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

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.

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.

COMMENTARY

Applying aviation factors to oral and maxillofacial surgery—the human element.

Seager L, Smith DW, Patel A, Brunt H, Brennan PA. Br J Oral Maxillofac Surg. 2013;51:8-13.

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.

NEWSPAPER/MAGAZINE ARTICLE

A hospital races to learn lessons of Ferrari pit stop.

Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].

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