AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (6)

•Diagnostic Errors (27)

•Identification Errors (3)

•Discontinuities, Gaps, and Hand-Off Problems (63)

•Fatigue and Sleep Deprivation (57)

•Medication Safety (80)

•Medical Complications (39)

•Nonsurgical Procedural Complications (14)

•Surgical Complications (73)

•Psychological and Social Complications (38)

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•Asia (6)

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•Journal Article (536)

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Error Types

•Epidemiology of Errors and Adverse Events (87)

•Active Errors (70)

•Latent Errors (22)

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Approach to Improving Safety

•Quality Improvement Strategies (75)

•Legal and Policy Approaches (28)

•Error Reporting and Analysis (100)

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•Human Factors Engineering (31)

•Teamwork (138)

•Specialization of Care (20)

•Logistical Approaches (88)

•Culture of Safety (86)

•Technologic Approaches (36)

•Education and Training (536)

Clinical Areas

•Allied Health Services (3)

•Complementary and Alternative Medicine (1)

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Educators

Setting of Care

•Hospitals (363)

•Residential Facilities (4)

•Ambulatory Care (33)

•Outpatient Surgery (1)

•Patient Transport (1)

1 - 20 of 631

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STUDY

A multidisciplinary teamwork training program: The Triad for Optimal Patient Safety (TOPS) experience.

Sehgal NL, Fox M, Vidyarthi AR, et al; TOPS Project. J Gen Intern Med. 2008;23:2053-2057.

STUDY

Improving prescription drug warnings to promote patient comprehension.

Wolf MS, Davis TC, Bass PF, et al. Arch Intern Med. 2010;170:50-56.

STUDY

Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project.

Blegen MA, Sehgal NL, Alldredge BK, Gearhart S, Auerbach AD, Wachter RM. Qual Saf Health Care. 2010;19:346-350.

BOOK/REPORT

Medical Team Training.

Oakbrook, IL: Joint Commission Resources; 2008. ISBN: 9781599400921.

STUDY

A novel method for reproducibly measuring the effects of interventions to improve emotional climate, indices of team skills and communication, and threat to patient outcome in a high-volume thoracic surgery center.

Nurok M, Lipsitz S, Satwicz P, Kelly A, Frankel A. Arch Surg. 2010;145:489-495.

REVIEW

Outcomes of classroom-based team training interventions for multiprofessional hospital staff. A systematic review.

Rabøl LI, Østergaard D, Mogensen T. Qual Saf Health Care. 2010;19:e27.

COMMENTARY

Handoffs and communication: the underappreciated roles of situational awareness and inattentional blindness.

Gosbee J. Clin Obstet Gynecol. 2010;53:545-558.

STUDY

Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training Program improves the cardiopulmonary resuscitation code process.

Percarpio KB, Harris FS, Hatfield BA, et al. Jt Comm J Qual Patient Saf. 2010;36:424-429:AP1.

REVIEW

Safety learning system development—incident reporting component for family practice.

O'Beirne M, Sterling P, Reid R, Tink W, Hohman S, Norton P. Qual Saf Health Care. 2010;19:252-257.

COMMENTARY

Lethal Cap.

Schillinger D. AHRQ WebM&M [serial online]. March 2004.

BOOK/REPORT

Achieving Strong Teamwork Practices in Hospital Labor and Delivery Units.

Farley DO, Sorbero ME, Lovejoy SL, Salisbury M. Santa Monica, CA: Rand Corporation; 2010. ISBN: 9780833050557.

STUDY

Perspective: a business school view of medical interprofessional rounds: transforming rounding groups into rounding teams.

Bharwani AM, Harris GC, Southwick FS. Acad Med. 2012;87:1768-1771.

STUDY

The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases.

Wolf FA, Way LW, Stewart L. Ann Surg. 2010;252:477-485.

STUDY

Communication failure in the operating room.

Halverson AL, Casey JT, Andersson J, et al. Surgery. 2011;49:305-310.

STUDY

Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme.

Neily J, Mills PD, Lee P, et al. Qual Saf Health Care. 2010;19:360-364.

SPECIAL OR THEME ISSUE

Teamwork and Communication.

Pa Patient Saf Advis. June 2010;7(suppl 2):1-16.

STUDY

Crisis resource management: evaluating outcomes of a multidisciplinary team.

Jankouskas T, Bush MC, Murray B, et al. Simul Healthc. 2007;2:96-101.

COMMENTARY

Toward a definition of teamwork in emergency medicine.

Fernandez R, Kozlowski SWJ, Shapiro MJ, Salas E. Acad Emerg Med. 2008;15:1104-1112.

REVIEW

Teamwork in obstetric critical care.

Guise JM, Segel S. Best Pract Res Clin Obstet Gynaecol. 2008;22:937-951.

COMMENTARY

What are the critical success factors for team training in health care?

Salas E, Almeida SA, Salisbury M, et al. Jt Comm J Qual Patient Saf. 2009;35:398-405.

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