AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (17)

•Diagnostic Errors (2)

•Identification Errors (4)

•Discontinuities, Gaps, and Hand-Off Problems (15)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (34)

•Medical Complications (11)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (117)

•Transfusion Complications (1)

•Psychological and Social Complications (10)

Origin/Sponsor

•Australia and New Zealand (13)

•North America (140)

Resource Types

•Audiovisual (1)

•Book/Report (3)

•Clinical Guideline (2)

•Journal Article (159)

•Legislation/Regulation (4)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (21)

•Special or Theme Issue (8)

•Tools/Toolkit (1)

•Web Resource (6)

Error Types

•Epidemiology of Errors and Adverse Events (38)

•Active Errors (32)

•Latent Errors (14)

•Near Miss (3)

Approach to Improving Safety

•Quality Improvement Strategies (41)

•Legal and Policy Approaches (16)

•Error Reporting and Analysis (47)

•Communication Improvement (49)

•Human Factors Engineering (56)

•Teamwork (26)

•Specialization of Care (6)

•Logistical Approaches (13)

•Culture of Safety (19)

•Technologic Approaches (25)

•Education and Training (53)

Clinical Areas
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Anesthesiology

Target Audience

•Health Care Providers (173)

•Health Care Executives and Administrators (133)

•Non-Health Care Professionals (65)

•Patients (15)

Setting of Care

•Hospitals (165)

•Ambulatory Care (7)

•Outpatient Surgery (7)

•Patient Transport (1)

1 - 20 of 208

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NEWSPAPER/MAGAZINE ARTICLE

Frederick mother's burning inspires daughter's activism.

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

NEWSPAPER/MAGAZINE ARTICLE

The day Joy died.

Brandeland GP. Med Econ. 2006 Oct 20;83:50, 52-53.

NEWSPAPER/MAGAZINE ARTICLE

Surgery fires spur need for new guidelines.

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

REVIEW

Life after death: the aftermath of perioperative catastrophes.

Gazoni FM, Durieux ME, Wells L. Anesth Analg. 2008;107:591-600.

MULTI-USE WEBSITE

Anesthesia Awareness Registry.

American Society of Anesthesiologists Committee on Professional Liability.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

CLINICAL GUIDELINE

Practice Advisory on Intraoperative Awareness and Brain Function Monitoring.

ASA Task Force on Intraoperative Awareness and Brain Function Monitoring. Park Ridge, IL: American Society of Anesthesiologists; July 2005.

NEWSPAPER/MAGAZINE ARTICLE

When surgery goes wrong: weighing up the risks.

Feinmann J. The Independent. November 14, 2006.

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.

ORGANIZATIONAL POLICY/GUIDELINES

Practice advisory for the prevention and management of operating room fires.

Caplan RA, Barker SJ, Connis RT, et al; for American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology. 2008;108:786-801.

COMMENTARY

Unexplained Apnea under Anesthesia.

Barach P. AHRQ WebM&M [serial online]. February 2003.

STUDY

Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work.

Nemeth C, O’Connor M, Klock PA, Cook R. Org Stud. 2006;27:1011-1035.

COMMENTARY

Shortage of perioperative drugs: implications for anesthesia practice and patient safety.

De Oliveira GS Jr, Theilken LS, McCarthy RJ. Anesth Analg. 2011;113:1429-1435.

NEWSPAPER/MAGAZINE ARTICLE

One group of doctors changes its ways.

Hallinan JT. Post-Gazette.com. June 21, 2005.

COMMENTARY

JCAHO's National Patient Safety Goals 2006.

Catalano K. J Perianesth Nurs. February 2006;21:6-11.

STUDY

The impact of perioperative catastrophes on anesthesiologists: results of a national survey.

Gazoni FM, Amato PE, Malik ZM, Durieux ME. Anesth Analg. 2012;114:596-603.

NEWSPAPER/MAGAZINE ARTICLE

Trends influencing the cost of care and patient safety.

Clark R. Health Manage Tech. July 2006:18, 20-21.

NEWSPAPER/MAGAZINE ARTICLE

For patients, a list of hospital hazards.

Landro L. Wall Street Journal (Eastern edition). December 23, 2008;D2.

NEWSPAPER/MAGAZINE ARTICLE

Practicing on patients, real and otherwise.

Chen PW. New York Times. January 28, 2010.

STUDY

Time of day effects on the incidence of anesthetic adverse events.

Wright MC, Phillips-Bute B, Mark JB, et al. Qual Saf Health Care. 2006;15:258-263.

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