AHRQ Patient Safety Network

The Collection > Risk Managers

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Safety Target

•Device-related Complications (48)

•Diagnostic Errors (68)

•Identification Errors (33)

•Discontinuities, Gaps, and Hand-Off Problems (85)

•Fatigue and Sleep Deprivation (44)

•Medication Safety (254)

•Medical Complications (63)

•Nonsurgical Procedural Complications (32)

•Surgical Complications (131)

•Transfusion Complications (5)

•Psychological and Social Complications (28)

Origin/Sponsor

•Asia (20)

•Australia and New Zealand (28)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (696)

•Legislation/Regulation (9)

•Meeting/Conference (1)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (69)

•Press Release/Announcement (13)

•Special or Theme Issue (7)

•Tools/Toolkit (6)

•Web Resource (6)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (309)

•Active Errors (154)

•Latent Errors (47)

•Near Miss (25)

Approach to Improving Safety

•Quality Improvement Strategies (186)

•Legal and Policy Approaches (96)

•Error Reporting and Analysis (373)

•Communication Improvement (156)

•Human Factors Engineering (124)

•Teamwork (39)

•Specialization of Care (33)

•Logistical Approaches (71)

•Culture of Safety (64)

•Technologic Approaches (119)

•Education and Training (95)

Clinical Areas

•Allied Health Services (2)

•Medicine (586)

•Nursing (39)

•Pharmacy (80)

Target Audience
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Risk Managers

Setting of Care

•Hospitals (471)

•Psychiatric Facilities (2)

•Residential Facilities (11)

•Ambulatory Care (50)

•Outpatient Surgery (12)

•Patient Transport (9)

1 - 20 of 851

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BOOK/REPORT

Annual Benchmarking Report: Malpractice Risks in Surgery.

Cambridge, MA: CRICO/RMF Strategies; 2010.

STUDY

Nature, causes and consequences of unintended events in surgical units.

van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Br J Surg. 2010;97:1730-1740.

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

Human factors in pediatric anesthesia incidents.

Marcus R. Paediatr Anaesth. 2006;16:242-250.

COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

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.

STUDY

Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit.

Joy BF, Elliott E, Hardy C, Sullivan C, Backer CL, Kane JM. Pediatr Crit Care Med. 2011;12:304-308.

STUDY

Using an enhanced oral chemotherapy computerized provider order entry system to reduce prescribing errors and improve safety.

Collins CM, Elsaid KA. Int J Qual Health Care. 2011;23:36-43.

STUDY

Impact of implementing alerts about medication black-box warnings in electronic health records.

Yu DT, Seger DL, Lasser KE, et al. Pharmacoepidemiol Drug Saf. 2011;20:192-202.

STUDY

Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit.

Boat AC, Spaeth JP. Paediatr Anaesth. 2013 May 18; [Epub ahead of print].

REVIEW

Avoiding wrong site surgery: a systematic review.

DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.

STUDY

Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home.

Lee BH, Lehmann CU, Jackson EV, et al. J Pain. 2009;10:160-166.

STUDY

Effect of a 19-item surgical safety checklist during urgent operations in a global patient population.

Weiser TG, Haynes AB, Dziekan G, et al; Safe Surgery Saves Lives Investigators and Study Group. Ann Surg. 2010;251:976-980.

COMMENTARY

Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.

Thyen AB, McAllister RK, Councilman LM. J Patient Saf. 2010;6:244-246.

STUDY

Near-miss events are really missed! Reflections on incident reporting in a department of pediatric surgery.

Mattioli G, Guida E, Montobbio G, et al. Pediatr Surg Int. 2012;28:405-410.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:282-287.

STUDY

Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program.

Kiran RP, Ahmed Ali U, Coffey JC, Vogel JD, Pokala N, Fazio VW. Ann Surg. 2012;256:469-475.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2010;45:13-17.

STUDY

Infrequent physician use of implantable cardioverter-defibrillators risks patient safety.

Lyman S, Sedrakyan A, Do H, Razzano R, Mushlin AI. Heart. 2011;97:1655-1660.

STUDY

Classification of adverse events occurring in a surgical intensive care unit.

Frankel H, Sperry J, Kaplan L, Foley A, Rabinovici R. Am J Surg. 2007;194:328-332.

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