AHRQ Patient Safety Network

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•Device-related Complications (25)

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Error Types

•Epidemiology of Errors and Adverse Events (204)

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Approach to Improving Safety

•Quality Improvement Strategies (185)

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Surgery

•Cardiothoracic Surgery (23)

•General Surgery (39)

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•Pediatric Surgery (29)

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•Surgical Oncology (11)

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Target Audience

•Health Care Providers (609)

•Health Care Executives and Administrators (593)

•Non-Health Care Professionals (244)

•Patients (85)

Setting of Care

•Hospitals (715)

•Residential Facilities (2)

•Ambulatory Care (16)

•Outpatient Surgery (48)

•Patient Transport (2)

1 - 20 of 820

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COMMENTARY

Learning from adverse events and near misses.

Greenberg CC. J Gastrointest Surg. 2008;13:3-5.

STUDY

Developing and pilot testing practical measures of preanalytic surgical specimen identification defects.

Bixenstine PJ, Zarbo RJ, Holzmueller CG, et al. Am J Med Qual. 2013 Jan 15; [Epub ahead of print].

COMMENTARY

Reducing surgical complications.

Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:660-665.

COMMENTARY

Preventable errors in organ transplantation: an emerging patient safety issue?

Ison MG, Holl JL, Ladner D. Am J Transplant. 2012;12:2307-2312.

ORGANIZATIONAL POLICY/GUIDELINES

Recommendations for quality assurance and improvement in surgical and autopsy pathology.

Association of Directors of Anatomic and Surgical Pathology. Hum Pathol. 2006;37:985-988.

MULTI-USE WEBSITE

Council on Surgical and Perioperative Safety.

Council on Surgical and Perioperative Safety; 633 N. St. Clair St. Chicago, IL, 60611.

COMMENTARY

Complications in surgery: root cause analysis and preventive measures.

Chung KC, Kotsis SV. Plast Reconstr Surg. 2012;129:1421-1427.

COMMENTARY

Improving operating room and perioperative safety: background and specific recommendations.

Schimpff SC. Surg Innov. 2007;14:127-135.

NEWSPAPER/MAGAZINE ARTICLE

Lost surgical specimens, lost opportunities.

PA-PSRS Patient Saf Advis. September 2005;2:1-5.

COMMENTARY

Case study: preventing surgical complications at Baystate Medical Center.

Fitzgerald J, Kanter G, Benjamin E. Jt Comm J Qual Patient Saf. 2007;33:666-671.

STUDY

Preventable morbidity at a mature trauma center.

Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.

STUDY

A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II.

Antonacci AC, Lam S, Lavarias V, Homel P, Eavey RA. J Surg Res. 2009;153:95-104.

COMMENTARY

Executive summary of the American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting: reinvigorating safety in office-based gynecologic surgery.

Erickson TB, Kirkpatrick DH, DeFrancesco MS, Lawrence HC III. Obstet Gynecol. 2010;115:147-151.

COMMENTARY

Surgical team training: promoting high reliability with nontechnical skills.

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

STUDY

Surgical case listing accuracy: failure analysis at a high-volume academic medical center.

Cima RR, Hale C, Kollengode A, Rogers JC, Cassivi SD, Deschamps C. Arch Surg. 2010;145:641-646.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

STUDY

Nature, causes and consequences of unintended events in surgical units.

van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Br J Surg. 2010;97:1730-1740.

STUDY

Improved operating room teamwork via SAFETY prep: a rural community hospital's experience.

Paige JT, Aaron DL, Yang T, Howell DS, Chauvin SW. World J Surg. 2009;33:1181-1187.

STUDY

Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.

Steinberger DM, Douglas SV, Kirschbaum MS. Prog Transplant. 2009;19:208-215.

STUDY

Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention.

Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. BMJ Qual Saf. 2011;20:102-107.

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