AHRQ Patient Safety Network

The Collection > Surgery

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Safety Target

•Device-related Complications (29)

•Diagnostic Errors (23)

•Identification Errors (81)

•Discontinuities, Gaps, and Hand-Off Problems (69)

•Fatigue and Sleep Deprivation (29)

•Medication Safety (59)

•Medical Complications (63)

•Nonsurgical Procedural Complications (10)

•Surgical Complications (645)

•Transfusion Complications (3)

•Psychological and Social Complications (41)

Origin/Sponsor

•Africa (1)

•Asia (8)

•Australia and New Zealand (18)

•Central and South America (1)

Resource Types

•Clinical Guideline (4)

•Journal Article (638)

•Legislation/Regulation (10)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (91)

•Press Release/Announcement (3)

•Special or Theme Issue (9)

•Tools/Toolkit (13)

•Web Resource (19)

Error Types

•Epidemiology of Errors and Adverse Events (196)

•Active Errors (171)

•Latent Errors (51)

•Near Miss (20)

Approach to Improving Safety

•Quality Improvement Strategies (184)

•Legal and Policy Approaches (56)

•Error Reporting and Analysis (210)

•Communication Improvement (256)

•Human Factors Engineering (182)

•Teamwork (140)

•Specialization of Care (23)

•Logistical Approaches (59)

•Culture of Safety (85)

•Technologic Approaches (84)

•Education and Training (200)

Clinical Areas
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Surgery

•Cardiothoracic Surgery (22)

•General Surgery (35)

•Neurosurgery (19)

•Otolaryngology (10)

•Orthopedic Surgery (23)

•Pediatric Surgery (30)

•Plastic Surgery (8)

•Surgical Oncology (8)

•Urology (7)

•Vascular Surgery (8)

Target Audience

•Health Care Providers (617)

•Health Care Executives and Administrators (575)

•Non-Health Care Professionals (241)

•Patients (92)

Setting of Care

•Hospitals (738)

•Residential Facilities (2)

•Ambulatory Care (14)

•Outpatient Surgery (38)

•Patient Transport (4)

1 - 20 of 819

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NEWSPAPER/MAGAZINE ARTICLE

Clinic sued over towel left in patient.

McCarty JF. Plain Dealer. January 16, 2007:A1.

COMMENTARY

Counting matters: lessons from the root cause analysis of a retained surgical item.

Agrawal A. Jt Comm J Qual Patient Saf. 2012;38:566-574.

STUDY

Simulation-based trial of surgical-crisis checklists.

Arriaga AF, Bader AM, Wong JM, et al. N Engl J Med. 2013;368:246-253.

COMMENTARY

Environmental Safety in the OR.

Linkin DR, Lautenbach E. AHRQ WebM&M [serial online]. February 2004.

STUDY

Gossypiboma: tales of lost sponges and lessons learned.

McIntyre LK, Jurkovich GJ, Gunn MLD, Maier RV. Arch Surg. 2010;145:770-775.

REVIEW

Improving safety in the operating room: a systematic literature review of retained surgical sponges.

Wan W, Le T, Riskin L, Macario A. Curr Opin Anaesthesiol. 2009;22:207-214.

STUDY

Do micropauses prevent surgeon's fatigue and loss of accuracy associated with prolonged surgery? An experimental prospective study.

Dorion D, Darveau S. Ann Surg. 2013;257:256-259.

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

Surgical never events in the United States.

Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgery. 2013;153:465-472.

COMMENTARY

Surgical count practice variability and the potential for retained surgical items.

Edel EM. AORN J. 2012;95:228-238.

COMMENTARY

JCAHO's National Patient Safety Goals 2006.

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

NEWSPAPER/MAGAZINE ARTICLE

Doctor removes ovaries from wrong patient.

Bramson K, Mooney T. Providence Journal. August 18, 2006.

STUDY

Surgical team behaviors and patient outcomes.

Mazzocco K, Petitti DB, Fong KT, et al. Am J Surg. 2009;197:678-685.

NEWSPAPER/MAGAZINE ARTICLE

A hospital races to learn lessons of Ferrari pit stop.

Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].

STUDY

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.

REVIEW

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

STUDY

Hospital process compliance and surgical outcomes in Medicare beneficiaries.

Nicholas LH, Osborne NH, Birkmeyer JD, Dimick JB. Arch Surg. 2010;145:999-1004.

COMMENTARY

The competent surgeon: individual accountability in the era of "systems" failure.

Whittemore AD. Ann Surg. 2009;250:357-362.

NEWSPAPER/MAGAZINE ARTICLE

The day Joy died.

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

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