AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (6)

•Diagnostic Errors (12)

•Identification Errors (7)

•Discontinuities, Gaps, and Hand-Off Problems (53)

•Fatigue and Sleep Deprivation (12)

•Medication Safety (78)

•Medical Complications (38)

•Nonsurgical Procedural Complications (6)

•Surgical Complications (81)

•Psychological and Social Complications (143)

Origin/Sponsor

•Australia and New Zealand (37)

•Europe (115)

•North America (485)

Resource Types

•Audiovisual (2)

•Book/Report (40)

•Journal Article (554)

•Legislation/Regulation (3)

•Meeting/Conference (8)

•Newspaper/Magazine Article (42)

•Press Release/Announcement (1)

•Special or Theme Issue (10)

•Tools/Toolkit (4)

•Web Resource (5)

Error Types

•Epidemiology of Errors and Adverse Events (63)

•Active Errors (61)

•Latent Errors (40)

•Near Miss (13)

Approach to Improving Safety

•Quality Improvement Strategies (146)

•Legal and Policy Approaches (54)

•Error Reporting and Analysis (180)

•Communication Improvement (218)

•Human Factors Engineering (64)

•Teamwork (175)

•Specialization of Care (31)

•Logistical Approaches (40)

•Culture of Safety (215)

•Technologic Approaches (51)

•Education and Training (166)

Clinical Areas

•Allied Health Services (3)

•Dentistry (1)

•Medicine (383)

•Nursing (80)

•Pharmacy (22)

Target Audience
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Organizational Behaviorists

Setting of Care

•Hospitals (386)

•Psychiatric Facilities (1)

•Residential Facilities (5)

•Ambulatory Care (33)

•Outpatient Surgery (1)

•Patient Transport (6)

1 - 20 of 669

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STUDY

Distractions and the anaesthetist: a qualitative study of context and direction of distraction.

Jothiraj H, Howland-Harris J, Evley R, Moppett IK. Br J Anaesth. 2013 Apr 16; [Epub ahead of print].

STUDY

No simple fix for fixation errors: cognitive processes and their clinical applications.

Fioratou E, Flin R, Glavin R. Anaesthesia. 2010;65:61-69.

STUDY

Barriers to adverse event and error reporting in anesthesia.

Heard GC, Sanderson PM, Thomas RD. Anesth Analg. 2012;114:604-614.

STUDY

Harvey Cushing's open and thorough documentation of surgical mishaps at the dawn of neurologic surgery.

Latimer K, Pendleton C, Olivi A, Cohen-Gadol AA, Brem H, Quiñones-Hinojosa A. Arch Surg. 2011;146:226-232.

STUDY

classic

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

Makary MA, Sexton JB, Freischlag JA, et al. J Am Coll Surg. 2006;202:746-752.

COMMENTARY

Barbers of civility.

Klein AS, Forni PM. Arch Surg. 2011;146:774-777.

STUDY

Burnout and medical errors among American surgeons.

Shanafelt TD, Balch CM, Bechamps G, et al. Ann Surg. 2010;251:995-1000.

STUDY

Poor resident–attending intraoperative communication may compromise patient safety.

Belyansky I, Martin TR, Prabhu AS, et al. J Surg Res. 2011;171:386-394.

STUDY

Framing family conversation after early diagnosis of iatrogenic injury and incidental findings.

Barrios L, Tsuda S, Derevianko A, et al. Surg Endosc. 2009;23:2535-2542.

STUDY

A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes.

Schraagen JM, Schouten T, Smit M, et al. BMJ Qual Saf. 2011;20:599-603.

REVIEW

Enhancing communication in surgery through team training interventions: a systematic literature review.

Gillespie BM, Chaboyer W, Murray P. AORN J. 2010;92:642-657.

STUDY

The relationship of the emotional climate of work and threat to patient outcome in a high-volume thoracic surgery operating room team.

Nurok M, Evans LA, Lipsitz S, Satwicz P, Kelly A, Frankel A. BMJ Qual Saf. 2011;20:237-242.

STUDY

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

Sexton JB, Makary MA, Tersigni AR, et al. Anesthesiology. 2006;105:877-884.

REVIEW

Health care professionals as second victims after adverse events: a systematic review.

Seys D, Wu AW, Van Gerven E, et al. Eval Health Prof. 2013;36:135-162.

STUDY

Failure to engage hospitalized elderly patients and their families in advance care planning.

Heyland DK, Barwich D, Pichora D, et al; ACCEPT (Advance Care Planning Evaluation in Elderly Patients) Study Team; Canadian Researchers at the End of Life Network (CARENET). JAMA Intern Med. 2013 Apr 1; [Epub ahead of print].

STUDY

A multidisciplinary team approach to retained foreign objects.

Cima RR, Kollengode A, Storsveen AS, et al. Jt Comm J Qual Patient Saf. 2009;35:123-132.

REVIEW

The disclosure of unanticipated outcomes of care and medical errors: what does this mean for anesthesiologists?

Souter KJ, Gallagher TH. Anesth Analg. 2012;114:615-621.

STUDY

Violations of behavioral practices revealed in closed claims reviews.

Griffen FD, Stephens LS, Alexander JB, et al. Ann Surg. 2008;248:468-474.

STUDY

Patient safety in surgery.

Makary MA, Sexton JB, Freischlag JA, et al. Ann Surg. 2006;243:628-635.

STUDY

Does teamwork improve performance in the operating room? A multilevel evaluation.

Weaver SJ, Rosen MA, DiazGranados D, et al. Jt Comm J Qual Patient Saf. 2010;36:133-142.

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