AHRQ Patient Safety Network

The Collection > Quality and Safety Professionals

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Safety Target

•Device-related Complications (124)

•Diagnostic Errors (126)

•Identification Errors (90)

•Discontinuities, Gaps, and Hand-Off Problems (276)

•Fatigue and Sleep Deprivation (57)

•Medication Safety (772)

•Medical Complications (303)

•Nonsurgical Procedural Complications (79)

•Surgical Complications (382)

•Transfusion Complications (13)

•Psychological and Social Complications (72)

Origin/Sponsor

•Africa (2)

•Asia (48)

•Australia and New Zealand (93)

•Central and South America (8)

•Europe (411)

•North America (1881)

Resource Types

•Audiovisual (10)

•Award (5)

•Book/Report (72)

•Clinical Guideline (3)

•Journal Article (2094)

•Legislation/Regulation (31)

•Meeting/Conference (12)

•Newsletter/Journal (4)

•Newspaper/Magazine Article (133)

•Press Release/Announcement (16)

•Special or Theme Issue (29)

•Tools/Toolkit (20)

•Web Resource (43)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (758)

•Active Errors (472)

•Latent Errors (152)

•Near Miss (55)

Approach to Improving Safety

•Quality Improvement Strategies (625)

•Legal and Policy Approaches (119)

•Error Reporting and Analysis (723)

•Communication Improvement (553)

•Human Factors Engineering (425)

•Teamwork (248)

•Specialization of Care (172)

•Logistical Approaches (175)

•Culture of Safety (293)

•Technologic Approaches (446)

•Education and Training (477)

Clinical Areas

•Allied Health Services (7)

Target Audience
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Quality and Safety Professionals

Setting of Care

•Hospitals (1648)

•Psychiatric Facilities (7)

•Residential Facilities (36)

•Ambulatory Care (176)

•Outpatient Surgery (24)

•Patient Transport (18)

1 - 20 of 2477

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REVIEW

Avoiding wrong site surgery: a systematic review.

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

STUDY

Process changes to increase compliance with the Universal Protocol for bedside procedures.

Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.

STUDY

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

STUDY

Variation in surgical time-out and site marking within pediatric otolaryngology.

Shah RK, Arjmand E, Roberson DW, Deutsch E, Derkay C. Arch Otolaryngol Head Neck Surg. 2011;137:69-73.

REVIEW

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.

STUDY

Medical errors in orthopaedics. Results of an AAOS member survey.

Wong DA, Herndon JH, Canale ST, et al. J Bone Joint Surg Am. 2009;91:547-557.

STUDY

Wrong-site craniotomy: analysis of 35 cases and systems for prevention.

Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473.

STUDY

Wrong site surgery near misses and actual occurrences.

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

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

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-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.

Stahel PF, Sabel AL, Victoroff MS, et al. Arch Surg. 2010;145:978-984.

STUDY

Incorrect surgical procedures within and outside of the operating room.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

STUDY

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.

STUDY

Application of human error theory in case analysis of wrong procedures.

Duthie EA. J Patient Saf. 2010;6:108-114.

STUDY

Wrong-site sinus surgery in otolaryngology.

Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.

STUDY

Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.

Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.

COMMENTARY classic

A 62-year-old woman with skin cancer who experienced wrong-site surgery.

Gallagher TH. JAMA. 2009;302:669-677.

REVIEW

Determining the state of knowledge for implementing the Universal Protocol recommendations: an integrative review of the literature.

Conrardy JA, Brenek B, Myers S. AORN J. 2010;92:194-207.

REVIEW

Spinal surgery and patient safety: a systems approach.

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

ORGANIZATIONAL POLICY/GUIDELINES

Safe Site Invasive Procedure—Non-Operating Room.

Bloomington, MN: Institute for Clinical Systems Improvement; 2010.

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