AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (42)

•Diagnostic Errors (57)

•Identification Errors (33)

•Discontinuities, Gaps, and Hand-Off Problems (87)

•Fatigue and Sleep Deprivation (37)

•Medication Safety (211)

•Medical Complications (44)

•Nonsurgical Procedural Complications (25)

•Surgical Complications (124)

•Transfusion Complications (6)

•Psychological and Social Complications (28)

Origin/Sponsor

•Asia (13)

•Australia and New Zealand (15)

Resource Types

•Clinical Guideline (1)

•Journal Article (578)

•Legislation/Regulation (9)

•Meeting/Conference (2)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (66)

•Press Release/Announcement (10)

•Special or Theme Issue (6)

•Tools/Toolkit (5)

•Web Resource (6)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (235)

•Active Errors (130)

•Latent Errors (42)

•Near Miss (22)

Approach to Improving Safety

•Quality Improvement Strategies (165)

•Legal and Policy Approaches (92)

•Error Reporting and Analysis (294)

•Communication Improvement (152)

•Human Factors Engineering (114)

•Teamwork (40)

•Specialization of Care (28)

•Logistical Approaches (66)

•Culture of Safety (53)

•Technologic Approaches (102)

•Education and Training (88)

Clinical Areas

•Allied Health Services (2)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (396)

•Psychiatric Facilities (4)

•Residential Facilities (9)

•Ambulatory Care (49)

•Outpatient Surgery (11)

•Patient Transport (10)

1 - 20 of 714

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BOOK/REPORT

Quality of Care in Cranial Implant Surgeries at James A. Haley VA Medical Center, Tampa, Florida.

Health Care Inspection. Washington, DC: VA Office of Inspector General; April 10, 2006. Report No. 06-01642-126.

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.

NEWSPAPER/MAGAZINE ARTICLE

Safety in ASCs: putting patients first.

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

ORGANIZATIONAL POLICY/GUIDELINES

Statement on the prevention of retained foreign bodies after surgery.

Bulletin of the American College of Surgeons; October 2005.

STUDY

Effectiveness of a radiofrequency detection system as an adjunct to manual counting protocols for tracking surgical sponges: a prospective trial of 2,285 patients.

Rupp CC, Kagarise MJ, Nelson SM, et al. J Am Coll Surg. 2012;215:524-533.

STUDY

Observational assessment of surgical teamwork: a feasibility study.

Undre S, Healey AN, Darzi A, Vincent CA. World J Surg. 2006;30:1774-1783.

STUDY

An examination of technical efficiency, quality, and patient safety in acute care nursing units.

Mark B, Jones C, Lindley L, Ozcan Y. Policy Polit Nurs Pract. 2009;10:180-186.

COMMENTARY

Detection of patient risk by nurses: a theoretical framework.

Despins LA, Scott-Cawiezell J, Rouder JN. J Adv Nurs. 2010;66:465-474.

STUDY

Infants at risk: when nurse fatigue jeopardizes quality care.

Dean GE, Scott LD, Rogers AE. Adv Neonatal Care. 2006;6:120-126.

STUDY

Improving patient safety by understanding past experiences in day surgery and PACU.

Ross J, Ranum D. J Perianesth Nurs. 2009;24:144-151.

STUDY

Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.

Kaplan LJ, Maerz LL, Schuster K, et al. J Trauma. 2009;67:173-179.

STUDY

Retained surgical items: a problem yet to be solved.

Stawicki SP, Moffatt-Bruce SD, Ahmed HM, et al. J Am Coll Surg. 2013;216:15-22.

REVIEW

Spinal surgery and patient safety: a systems approach.

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

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.

COMMENTARY

Preventing sentinel events caused by family members.

Wall Y, Kautz DD. Dimens Crit Care Nurs. 2011;30:25-27.

COMMENTARY

Shortage of perioperative drugs: implications for anesthesia practice and patient safety.

De Oliveira GS Jr, Theilken LS, McCarthy RJ. Anesth Analg. 2011;113:1429-1435.

STUDY

In search of common ground in handoff documentation in an intensive care unit.

Collins SA, Mamykina L, Jordan D, et al. J Biomed Inform. 2012;45:307-315.

STUDY

Deconstructing intraoperative communication failures.

Hu YY, Arriaga AF, Peyre SE, Corso KA, Roth EM, Greenberg CC. J Surg Res. 2012;177:37-42.

STUDY

Gossypiboma: tales of lost sponges and lessons learned.

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

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