AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (47)

•Diagnostic Errors (68)

•Identification Errors (35)

•Discontinuities, Gaps, and Hand-Off Problems (86)

•Fatigue and Sleep Deprivation (45)

•Medication Safety (255)

•Medical Complications (60)

•Nonsurgical Procedural Complications (30)

•Surgical Complications (129)

•Transfusion Complications (5)

•Psychological and Social Complications (27)

Origin/Sponsor

•Australia and New Zealand (27)

•Central and South America (1)

•Europe (119)

•North America (636)

Resource Types

•Audiovisual (7)

•Book/Report (30)

•Clinical Guideline (1)

•Journal Article (691)

•Legislation/Regulation (9)

•Meeting/Conference (2)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (68)

•Press Release/Announcement (13)

•Special or Theme Issue (6)

•Tools/Toolkit (6)

•Web Resource (6)

Error Types

•Epidemiology of Errors and Adverse Events (284)

•Active Errors (154)

•Latent Errors (49)

•Near Miss (25)

Approach to Improving Safety

•Quality Improvement Strategies (192)

•Legal and Policy Approaches (100)

•Error Reporting and Analysis (368)

•Communication Improvement (158)

•Human Factors Engineering (119)

•Teamwork (41)

•Specialization of Care (33)

•Logistical Approaches (72)

•Culture of Safety (64)

•Technologic Approaches (122)

•Education and Training (99)

Clinical Areas

•Allied Health Services (2)

•Medicine (569)

•Nursing (44)

•Pharmacy (81)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (460)

•Psychiatric Facilities (4)

•Residential Facilities (12)

•Ambulatory Care (52)

•Outpatient Surgery (12)

•Patient Transport (10)

1 - 20 of 845

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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.

STUDY

classic

Operating room briefings and wrong-site surgery.

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

NEWSPAPER/MAGAZINE ARTICLE

Safety in ASCs: putting patients first.

Dix K. Today's Surgicenter. December 1, 2006.

STUDY

Representative case series from public hospital admissions 1998 II: surgical adverse events.

Briant R, Morton J, Lay-Yee R, Davis P, Ali W. N Z Med J. 2005;118:U1591.

ORGANIZATIONAL POLICY/GUIDELINES

Statement on the prevention of retained foreign bodies after surgery.

Bulletin of the American College of Surgeons; October 2005.

COMMENTARY

Wrong site surgery.

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

STUDY

Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology.

Macario A, Morris D, Morris S. Arch Surg. 2006;141:659-662.

REVIEW

Communication devices in the operating room.

Ruskin KJ. Curr Opin Anaesthesiol. 2006;19:655-659.

STUDY

Patient characteristics and the occurrence of never events.

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

COMMENTARY

'Balancing risk, that is my life': The politics of risk in a hospital operating theatre department.

McDonald R, Waring J, Harrison S. Health Risk Soc. 2005;7:397-411.

BOOK/REPORT

Annual Benchmarking Report: Malpractice Risks in Surgery.

Cambridge, MA: CRICO/RMF Strategies; 2010.

NEWSPAPER/MAGAZINE ARTICLE

What pilots can teach hospitals about patient safety.

Murphy K. New York Times. October 31, 2006:F5.

STUDY

Postoperative sepsis in the United States.

Vogel TR, Dombrovskiy VY, Carson JL, Graham AM, Lowry SF. Ann Surg. 2010;252:1065-1071.

NEWSPAPER/MAGAZINE ARTICLE

Promethazine conundrum: IV can hurt more than IM injection!

ISMP Medication Safety Alert! Acute Care Edition. November 2, 2006;11:1-3.

STUDY

Time of day effects on the incidence of anesthetic adverse events.

Wright MC, Phillips-Bute B, Mark JB, et al. Qual Saf Health Care. 2006;15:258-263.

STUDY

Validity of selected patient safety indicators: opportunities and concerns.

Kaafarani HM, Borzecki AM, Itani KM, et al. J Am Coll Surg. 2011; 212:924-934.

COMMENTARY

An Ounce of Prevention

Kucher N. AHRQ WebM&M [serial online]. January 2006.

COMMENTARY

Right? Left? Neither!

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

CONGRESSIONAL TESTIMONY

Oversight hearing on recent patient safety issues.

Subcommittee on Oversight and Investigations, 109th Cong, 2nd Sess (June 15, 2006). (Testimony of James P. Bagian, MD, PE; John D. Daigh, Jr., MD; Daniel Schultz, MD; Laurie Ekstrand).

REVIEW

Spinal surgery and patient safety: a systems approach.

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

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