AHRQ Patient Safety Network

The Collection > Surgery

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Safety Target

•Device-related Complications (24)

•Diagnostic Errors (21)

•Identification Errors (50)

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

•Fatigue and Sleep Deprivation (24)

•Medication Safety (58)

•Medical Complications (62)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (574)

•Transfusion Complications (3)

•Psychological and Social Complications (27)

Origin/Sponsor

•Africa (2)

•Asia (12)

•Australia and New Zealand (17)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (574)

•Legislation/Regulation (7)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (61)

•Press Release/Announcement (2)

•Special or Theme Issue (9)

•Tools/Toolkit (8)

•Web Resource (17)

Error Types

•Epidemiology of Errors and Adverse Events (219)

•Active Errors (123)

•Latent Errors (48)

•Near Miss (18)

Approach to Improving Safety

•Quality Improvement Strategies (164)

•Legal and Policy Approaches (44)

•Error Reporting and Analysis (203)

•Communication Improvement (214)

•Human Factors Engineering (161)

•Teamwork (129)

•Specialization of Care (22)

•Logistical Approaches (49)

•Culture of Safety (84)

•Technologic Approaches (67)

•Education and Training (173)

Clinical Areas
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Surgery

•Cardiothoracic Surgery (22)

•General Surgery (29)

•Neurosurgery (10)

•Otolaryngology (9)

•Orthopedic Surgery (14)

•Pediatric Surgery (25)

•Plastic Surgery (8)

•Surgical Oncology (8)

•Urology (2)

•Vascular Surgery (8)

Target Audience

•Health Care Providers (542)

•Health Care Executives and Administrators (534)

•Non-Health Care Professionals (224)

•Patients (58)

Setting of Care

•Hospitals (631)

•Residential Facilities (2)

•Ambulatory Care (14)

•Outpatient Surgery (42)

•Patient Transport (3)

1 - 20 of 710

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STUDY

Association between Leapfrog safe practices score and hospital mortality in major surgery.

Qian F, Lustik SJ, Diachun CA, Wissler RN, Zollo RA, Glance LG. Med Care. 2011;49:1082-1088.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

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

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2013.

STUDY

Sharing lessons learned to prevent incorrect surgery.

Neily J, Mills PD, Paull DE, et al. Am Surg. 2012;78:1276-1280.

STUDY

Association between implementation of a medical team training program and surgical mortality.

Neily J, Mills PD, Young-Xu Y, et al. JAMA. 2010;304:1693-1700.

BOOK/REPORT

MHA Keystone Center for Patient Safety & Quality 2010 Annual Report.

Lansing, MI: Michigan Health & Hospital Association; October 2010.

NEWSPAPER/MAGAZINE ARTICLE

Can your nurses stop a surgeon?

Weinstock M. Hosp Health Netw. 2007;81:38-40, 42, 44-46.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

STUDY

Factors that influence the expected length of operation: results of a prospective study.

Gillespie BM, Chaboyer W, Fairweather N. BMJ Qual Saf. 2012;21:3-12.

MULTI-USE WEBSITE

Standardization Projects.

Washington State Hospital Association.

COMMENTARY

Video technology to advance safety in the operating room and perioperative environment.

Xiao Y, Schimpff S, Mackenzie C, et al. Surg Innov. 2007;14:52-61.

STUDY

Communication failure in the operating room.

Halverson AL, Casey JT, Andersson J, et al. Surgery. 2011;49:305-310.

BOOK/REPORT

National Healthcare Quality Reports.

Rockville, MD: Agency for Healthcare Research and Quality; May 2013. AHRQ Publication No. 13-0002.

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.

COMMENTARY

What Was in Those Platelets?

Yomtovian R. AHRQ WebM&M [serial online]. July 2008.

STUDY

Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training.

Paull DE, Mazzia LM, Izu BS, Neily J, Mills PD, Bagian JP. Am J Surg. 2009;198:675-678.

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.

STUDY

Influence of house-staff experience on teaching-hospital mortality: the "July Phenomenon" revisited.

van Walraven C, Jennings A, Wong J, Forster AJ. J Hosp Med. 2011;6:389-394.

COMMENTARY

Organizational Change in the Face of Highly Public Errors—II. The Duke Experience

Frush K. AHRQ WebM&M [serial online]. May 2005.

STUDY

Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit.

McCulloch P, Kreckler S, New S, Sheena Y, Handa A, Catchpole K. BMJ. 2010;341:c5469.

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