AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (6)

•Diagnostic Errors (32)

•Identification Errors (3)

•Discontinuities, Gaps, and Hand-Off Problems (65)

•Fatigue and Sleep Deprivation (59)

•Medication Safety (83)

•Medical Complications (39)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (75)

•Psychological and Social Complications (39)

Origin/Sponsor

•Asia (8)

•Australia and New Zealand (15)

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Resource Types

•Journal Article (563)

•Legislation/Regulation (2)

•Meeting/Conference (1)

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•Newspaper/Magazine Article (24)

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•Special or Theme Issue (17)

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Error Types

•Epidemiology of Errors and Adverse Events (93)

•Active Errors (78)

•Latent Errors (20)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (84)

•Legal and Policy Approaches (28)

•Error Reporting and Analysis (106)

•Communication Improvement (178)

•Human Factors Engineering (37)

•Teamwork (140)

•Specialization of Care (21)

•Logistical Approaches (90)

•Culture of Safety (89)

•Technologic Approaches (35)

•Education and Training (561)

Clinical Areas

•Allied Health Services (3)

•Complementary and Alternative Medicine (1)

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Educators

Setting of Care

•Hospitals (375)

•Residential Facilities (4)

•Ambulatory Care (34)

•Outpatient Surgery (1)

•Patient Transport (1)

1 - 20 of 664

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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.

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.

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.

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

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

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

Communication and collaboration: it's about the pharmacists, as well as the physicians and nurses.

Holden LM, Watts DD, Walker PH. Qual Saf Health Care. 2010;19:169-172.

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.

STUDY

Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital.

Riley W, Davis S, Miller K, Hansen H, Sainfort F, Sweet R. Jt Comm J Qual Patient Saf. 2011;37:357-364.

STUDY

The computerized rounding report: implementation of a model system to support transitions of care.

Wohlauer MV, Rove KO, Pshak TJ, et al. J Surg Res. 2012;172:11-17.

STUDY

Content analysis of team communication in an obstetric emergency scenario.

Siassakos D, Draycott T, Montague I, Harris M. J Obstet Gynaecol. 2009;29:499-503.

STUDY

Interprofessional education in team communication: working together to improve patient safety.

Brock D, Abu-Rish E, Chiu CR, et al. BMJ Qual Saf. 2013;22:414-423.

STUDY

Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations.

Thomas EJ, Williams AL, Reichman EF, Lasky RE, Crandell S, Taggart WR. Pediatrics. 2010;125:539-546.

COMMENTARY

Enhancing patient safety in the pediatric emergency department: teams, communication, and lessons from crew resource management.

Pruitt CM, Liebelt EL. Pediatr Emerg Care. 2010;26:942-948.

COMMENTARY

Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue.

Young JQ, Wachter RM. JAMA. 2009;302:1327-1329.

STUDY

Use of the Safety Attitudes Questionnaire as a measure in patient safety improvement.

Watts BV, Percarpio K, West P, Mills PD. J Patient Saf. 2010;6:206-209.

COMMENTARY

Surgical team training: promoting high reliability with nontechnical skills.

Paige JT. Surg Clin North Am. 2010;90:569-581.

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