AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (25)

•Diagnostic Errors (2)

•Identification Errors (3)

•Discontinuities, Gaps, and Hand-Off Problems (18)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (43)

•Medical Complications (14)

•Nonsurgical Procedural Complications (13)

•Surgical Complications (134)

•Transfusion Complications (1)

•Psychological and Social Complications (10)

Origin/Sponsor

•Australia and New Zealand (15)

•North America (146)

Resource Types

•Audiovisual (1)

•Book/Report (4)

•Clinical Guideline (2)

•Journal Article (188)

•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 (47)

•Active Errors (39)

•Latent Errors (17)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (49)

•Legal and Policy Approaches (19)

•Error Reporting and Analysis (57)

•Communication Improvement (53)

•Human Factors Engineering (63)

•Teamwork (29)

•Specialization of Care (7)

•Logistical Approaches (14)

•Culture of Safety (24)

•Technologic Approaches (25)

•Education and Training (61)

Clinical Areas
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Anesthesiology

Target Audience

•Health Care Providers (196)

•Health Care Executives and Administrators (153)

•Non-Health Care Professionals (71)

•Patients (15)

Setting of Care

•Hospitals (184)

•Ambulatory Care (8)

•Outpatient Surgery (7)

•Patient Transport (2)

1 - 20 of 238

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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.

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.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.

STUDY

How does patient safety culture in the operating room and post-anesthesia care unit compare to the rest of the hospital?

Kaafarani HM, Itani KM, Rosen AK, Zhao S, Hartmann CW, Gaba DM. Am J Surg. 2009;198:70-75.

COMMENTARY

JCAHO's National Patient Safety Goals 2006.

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

STUDY

classic

Error, stress, and teamwork in medicine and aviation: cross sectional surveys.

Sexton JB, Thomas EJ, Helmreich RL. BMJ. 2000;320:745-749.

STUDY

Integrating incident reporting into an electronic patient record system.

Haller G, Myles PS, Stoelwinder J, Langley M, Anderson H, McNeil J. J Am Med Inform Assoc. 2007;14:175-181.

NEWSPAPER/MAGAZINE ARTICLE

The day Joy died.

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

STUDY

Factors associated with unanticipated day of surgery deaths in Department of Veterans Affairs hospitals.

Bishop MJ, Souders JE, Peterson CM, Henderson WG, Domino KB. Anesth Analg. 2008;107:1924-1935.

SPECIAL OR THEME ISSUE

Safety in Anaesthesia.

Staender S, ed. Best Pract Res Clin Anaesthesiol. 2011;25:109-304.

COMMENTARY

A common body of care: the ethics and politics of teamwork in the operating theater are inseparable.

Bleakley A. J Med Philos. 2006;31:305-322.

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.

REVIEW

Patient safety during anaesthesia: incorporation of the WHO safe surgery guidelines into clinical practice.

Schlack WS, Boermeester MA. Curr Opin Anaesthesiol. 2010;23:754-758.

STUDY

Information needs in operating room teams: what is right, what is wrong, and what is needed?

Wong HW, Forrest D, Healey A, et al. Surg Endosc. 2011;25:1913-1920.

STUDY

No harm found when nurse anesthetists work without supervision by physicians.

Dulisse B, Cromwell J. Health Aff (Millwood). 2010;29:1469-1475.

NEWSPAPER/MAGAZINE ARTICLE

Trends influencing the cost of care and patient safety.

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

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.

REVIEW

Decision-making and safety in anesthesiology.

Stiegler MP, Ruskin KJ. Curr Opin Anaesthesiol. 2012;25:724-729.

STUDY

classic

Rate of undesirable events at beginning of academic year: retrospective cohort study.

Haller G, Myles PS, Taffé P, Perneger TV, Wu CL. BMJ. 2009;339:b3974.

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.

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