AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (33)

•Diagnostic Errors (20)

•Identification Errors (40)

•Discontinuities, Gaps, and Hand-Off Problems (31)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (111)

•Medical Complications (52)

•Nonsurgical Procedural Complications (11)

•Surgical Complications (99)

•Transfusion Complications (4)

•Psychological and Social Complications (21)

Origin/Sponsor

•Australia and New Zealand (5)

Resource Types

•Journal Article (61)

•Legislation/Regulation (7)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (196)

•Press Release/Announcement (16)

•Special or Theme Issue (1)

•Tools/Toolkit (15)

•Web Resource (31)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (35)

•Active Errors (78)

•Latent Errors (53)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (96)

•Legal and Policy Approaches (111)

•Error Reporting and Analysis (142)

•Communication Improvement (136)

•Human Factors Engineering (58)

•Teamwork (18)

•Specialization of Care (12)

•Logistical Approaches (22)

•Culture of Safety (51)

•Technologic Approaches (64)

•Education and Training (78)

Clinical Areas

•Allied Health Services (1)

•Medicine (253)

•Nursing (14)

•Pharmacy (48)

Target Audience
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Patients

Setting of Care

•Hospitals (239)

•Psychiatric Facilities (1)

•Residential Facilities (5)

•Ambulatory Care (36)

•Outpatient Surgery (9)

•Patient Transport (1)

1 - 20 of 416

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ORGANIZATIONAL POLICY/GUIDELINES classic

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.

The Joint Commission.

STUDY

Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.

Espin S, Levinson W, Regehr G, Baker GR, Lingard L. Surgery. 2006;139:6-14.

COMMENTARY

Surgical site verification: A through Z.

Dunn D. J Perianesth Nurs. 2006;21:317-328.

NEWSPAPER/MAGAZINE ARTICLE

Surgery fires spur need for new guidelines.

Collins D. Associated Press [MSNBC]. July 26, 2007.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

Bernhard B. The Orange County Register. April 19, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Reused devices, surgery's deadly suspects.

Klein A. The Washington Post. December 30, 2005:A3.

NEWSPAPER/MAGAZINE ARTICLE

'Wrong site' surgeries on the rise.

Davis R. USA Today. April 17, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Frederick mother's burning inspires daughter's activism.

Levine S. Washington Post. July 18, 2006:B01.

NEWSPAPER/MAGAZINE ARTICLE

The horror of awakening during surgery.

Foreman J. Boston Globe. February 8, 2005.

NEWSPAPER/MAGAZINE ARTICLE

200 epidural blunders admitted after three women die.

Oakeshott I. The Sunday Times. June 18, 2006.

BOOK/REPORT

Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.

Baker M. Manchester, England: NHS North West; February 2007.

MULTI-USE WEBSITE

Strong for Surgery.

CERTAIN. Rockville, MD: Agency for Healthcare Research and Quality. SCOAP. Seattle, WA: Foundation for Health Care Quality.

REVIEW

Role of intraoperative cholangiography in avoiding bile duct injury.

Massarweh NN, Flum DR. J Am Coll Surg. 2007;204:656-664.

NEWSPAPER/MAGAZINE ARTICLE

New practices reduce childbirth risks.

Landro L. Wall Street Journal. July 12, 2006:D1. [Reprinted on Post-gazette.com].

AUDIOVISUAL

Dirty surgical tools put patients at risk.

Snyderman N. NBC News. February 22, 2012.

AUDIOVISUAL

Limiting medical mistakes.

Maminta J. News 8 WTNH. February 3, 2012.

NEWSPAPER/MAGAZINE ARTICLE

UTMC nurse tossed out kidney, ruined it. National experts say error is rare.

Messina I. Toledo Blade. August 24, 2012.

AUDIOVISUAL PRESENTATION

Washington man's face catches fire during routine surgical procedure.

Hopperstad J. KCPQ-TV. December 5, 2011.

NEWSPAPER/MAGAZINE ARTICLE

Accuracy at every step: the challenge of medication reconciliation.

Institute for Healthcare Improvement Web site. March 20, 2006.

NEWSPAPER/MAGAZINE ARTICLE

The consumer: and now, a warning about labels.

Franklin D. New York Times. October 25, 2005:F1.

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