AHRQ Patient Safety Network

The Collection > Quality and Safety Professionals

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Safety Target

•Device-related Complications (56)

•Diagnostic Errors (50)

•Identification Errors (54)

•Discontinuities, Gaps, and Hand-Off Problems (102)

•Fatigue and Sleep Deprivation (41)

•Medication Safety (264)

•Medical Complications (88)

•Nonsurgical Procedural Complications (34)

•Surgical Complications (363)

•Transfusion Complications (7)

•Psychological and Social Complications (33)

Origin/Sponsor

•Asia (16)

•Australia and New Zealand (34)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (897)

•Legislation/Regulation (10)

•Meeting/Conference (1)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (68)

•Press Release/Announcement (10)

•Special or Theme Issue (15)

•Tools/Toolkit (9)

•Web Resource (14)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (320)

•Active Errors (190)

•Latent Errors (63)

•Near Miss (29)

Approach to Improving Safety

•Quality Improvement Strategies (264)

•Legal and Policy Approaches (63)

•Error Reporting and Analysis (388)

•Communication Improvement (232)

•Human Factors Engineering (219)

•Teamwork (127)

•Specialization of Care (46)

•Logistical Approaches (74)

•Culture of Safety (126)

•Technologic Approaches (133)

•Education and Training (192)

Clinical Areas

•Allied Health Services (2)

•Complementary and Alternative Medicine (1)

Target Audience
< All

Quality and Safety Professionals

Setting of Care

•Hospitals (712)

•Psychiatric Facilities (3)

•Residential Facilities (9)

•Ambulatory Care (49)

•Outpatient Surgery (21)

•Patient Transport (6)

1 - 20 of 1064

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REVIEW

Surgical fires, a clear and present danger.

Yardley IE, Donaldson LJ. Surgeon. 2010;8:87-92.

STUDY

An evaluation of information transfer through the continuum of surgical care: a feasibility study.

Nagpal K, Vats A, Ahmed K, Vincent C, Moorthy K. Ann Surg. 2010;252:402-407.

STUDY

Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit.

McCulloch P, Kreckler S, New S, Sheena Y, Handa A, Catchpole K. BMJ. 2010;341:c5469.

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

Applicability of Healthcare Failure Mode and Effects Analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments.

Linkin DR, Sausman C, Santos L, et al. Clin Infect Dis. 2005;41:1014-1019.

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.

STUDY

'Skating on thin ice?' Consultant surgeon's contemporary experience of adverse surgical events.

Skevington SM, Langdon JE, Giddins G. Psychol Health Med. 2012;17:1-16.

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 safety in orthopedic surgery: prioritizing key areas of iatrogenic harm through an analysis of 48,095 incidents reported to a national database of errors.

Panesar SS, Carson-Stevens A, Salvilla SA, Patel B, Mirza SB, Mann B. Drug Healthc Patient Saf. 2013;5:57-65.

REVIEW

Towards a model of surgeons' leadership in the operating room.

Henrickson Parker S, Yule S, Flin R, McKinley A. BMJ Qual Saf. 2011;20:570-579.

COMMENTARY

Wrong site surgery.

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

STUDY

Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.

Steinberger DM, Douglas SV, Kirschbaum MS. Prog Transplant. 2009;19:208-215.

STUDY

Prevention of surgical malpractice claims by a surgical safety checklist.

de Vries EN, Eikens-Jansen MP, Hamersma AM, Smorenburg SM, Gouma DJ, Boermeester MA. Ann Surg. 2011;253:624-628.

STUDY

Factors influencing incident reporting in surgical care.

Kreckler S, Catchpole K, McCulloch P, Handa A. Qual Saf Health Care. 2009;18:116-120.

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.

STUDY

A systematic quantitative assessment of risks associated with poor communication in surgical care.

Nagpal K, Vats A, Ahmed K, et al. Arch Surg. 2010;145:582-588.

NEWSPAPER/MAGAZINE ARTICLE

Costly issues of an uncommunicative OR.

Neil R. Mat Manage Health Care. March 2006;15:30-33.

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.

STUDY

Quality and safety on an acute surgical ward: an exploratory cohort study of process and outcome.

Kreckler S, Catchpole KR, New SJ, Handa A, McCulloch PG. Ann Surg. 2009;250:1035-1040.

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