AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (48)

•Diagnostic Errors (62)

•Identification Errors (33)

•Discontinuities, Gaps, and Hand-Off Problems (80)

•Fatigue and Sleep Deprivation (42)

•Medication Safety (240)

•Medical Complications (60)

•Nonsurgical Procedural Complications (31)

•Surgical Complications (126)

•Transfusion Complications (5)

•Psychological and Social Complications (26)

Origin/Sponsor

•Asia (17)

•Australia and New Zealand (23)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (666)

•Legislation/Regulation (9)

•Meeting/Conference (2)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (68)

•Press Release/Announcement (16)

•Special or Theme Issue (9)

•Tools/Toolkit (6)

•Web Resource (7)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (264)

•Active Errors (146)

•Latent Errors (46)

•Near Miss (22)

Approach to Improving Safety

•Quality Improvement Strategies (185)

•Legal and Policy Approaches (103)

•Error Reporting and Analysis (361)

•Communication Improvement (154)

•Human Factors Engineering (122)

•Teamwork (42)

•Specialization of Care (31)

•Logistical Approaches (67)

•Culture of Safety (70)

•Technologic Approaches (115)

•Education and Training (93)

Clinical Areas

•Allied Health Services (2)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (443)

•Psychiatric Facilities (2)

•Residential Facilities (11)

•Ambulatory Care (52)

•Outpatient Surgery (11)

•Patient Transport (9)

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COMMENTARY

Have we gone too far in translating ideas from aviation to patient safety?

Rogers J, Gaba DM. BMJ. 2011;342:c7309-7310.

STUDY

A novel method for reproducibly measuring the effects of interventions to improve emotional climate, indices of team skills and communication, and threat to patient outcome in a high-volume thoracic surgery center.

Nurok M, Lipsitz S, Satwicz P, Kelly A, Frankel A. Arch Surg. 2010;145:489-495.

STUDY

Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections.

Wick EC, Hobson DB, Bennett JL, et al. J Am Coll Surg. 2012;215;193-200.

STUDY

What is the safety of nonemergent operative procedures performed at night?

Turrentine FE, Wang H, Young JS, Calland JF. J Trauma. 2010;69:313-319.

STUDY

Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety.

Einav Y, Gopher D, Kara I, et al. Chest. 2010;137:443-449.

STUDY

Gossypiboma: tales of lost sponges and lessons learned.

McIntyre LK, Jurkovich GJ, Gunn MLD, Maier RV. Arch Surg. 2010;145:770-775.

STUDY

Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after 1,946,831 operations in children.

Camp M, Chang DC, Zhang Y, Chrouser K, Colombani PM, Abdullah F. Arch Surg. 2010;145:1085-1090.

COMMENTARY

Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy.

Bellandi T, Albolino S, Tartaglia R, Filipponi F. Transplant Proc. 2010;42:2187-2189.

STUDY

Patient characteristics and the occurrence of never events.

Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.

STUDY

The influence of resident involvement on surgical outcomes.

Raval MV, Wang X, Cohen ME, et al. J Am Coll Surg. 2011;212:889-898.

STUDY

Safety culture and complications after bariatric surgery.

Birkmeyer NJ, Finks JF, Greenberg CK, et al. Ann Surg. 2013;257:260-265.

NEWSPAPER/MAGAZINE ARTICLE

DTaP–Tdap mix-ups now affecting hundreds of patients.

ISMP Medication Safety Alert! Acute Care Edition. July 1, 2010;15:1-2.

PRESS RELEASE/ANNOUNCEMENT

New dosing recommendations to prevent potential Valcyte (valganciclovir) overdose in pediatric transplant patients.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 15, 2010.

COMMENTARY

Relationships among teams, culture, safety, and cost outcomes.

Brewer BB. West J Nurs Res. 2006;28:641-653.

REVIEW

Quality in cancer diagnosis.

Raab SS, Grzybicki DM. CA Cancer J Clin. 2010;60:139-165.

COMMENTARY

Embedding quality improvement and patient safety at Liverpool Women's NHS Foundation Trust.

Scholefield H. Best Pract Res Clin Obstet Gynaecol. 2007;21:593-607.

NEWSPAPER/MAGAZINE ARTICLE

Naval aviation safety and its application to medicine.

Harmon KT. Patient Safety & Quality Healthcare. March/April 2006;3:20-26.

STUDY

Wrong site surgery near misses and actual occurrences.

Blanco M, Clarke JR, Martindell D. AORN J. 2009;90:215-222.

STUDY

A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards and improving patient safety.

Rodriguez-Paz JM, Mark LJ, Herzer KR, et al. Anesth Analg. 2009;108:202-210.

COMMENTARY

What went right: lessons for the intensivist from the crew of US Airways Flight 1549.

Eisen LA, Savel RH. Chest. 2009;136:910-917.

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