AHRQ Patient Safety Network

The Collection > Surgery

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Safety Target

•Device-related Complications (26)

•Diagnostic Errors (21)

•Identification Errors (77)

•Discontinuities, Gaps, and Hand-Off Problems (66)

•Fatigue and Sleep Deprivation (29)

•Medication Safety (55)

•Medical Complications (60)

•Nonsurgical Procedural Complications (8)

•Surgical Complications (668)

•Transfusion Complications (3)

•Psychological and Social Complications (41)

Origin/Sponsor

•Africa (2)

•Asia (10)

•Australia and New Zealand (15)

•Central and South America (1)

Resource Types

•Clinical Guideline (4)

•Journal Article (627)

•Legislation/Regulation (10)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (96)

•Press Release/Announcement (2)

•Special or Theme Issue (10)

•Tools/Toolkit (13)

•Web Resource (19)

Error Types

•Epidemiology of Errors and Adverse Events (192)

•Active Errors (165)

•Latent Errors (56)

•Near Miss (20)

Approach to Improving Safety

•Quality Improvement Strategies (178)

•Legal and Policy Approaches (61)

•Error Reporting and Analysis (211)

•Communication Improvement (250)

•Human Factors Engineering (181)

•Teamwork (142)

•Specialization of Care (21)

•Logistical Approaches (52)

•Culture of Safety (90)

•Technologic Approaches (75)

•Education and Training (200)

Clinical Areas
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Surgery

•Cardiothoracic Surgery (22)

•General Surgery (40)

•Neurosurgery (17)

•Otolaryngology (8)

•Orthopedic Surgery (22)

•Pediatric Surgery (24)

•Plastic Surgery (14)

•Surgical Oncology (5)

•Urology (6)

•Vascular Surgery (5)

Target Audience

•Health Care Providers (593)

•Health Care Executives and Administrators (556)

•Non-Health Care Professionals (243)

•Patients (95)

Setting of Care

•Hospitals (719)

•Residential Facilities (2)

•Ambulatory Care (14)

•Outpatient Surgery (43)

•Patient Transport (3)

1 - 20 of 812

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NEWSPAPER/MAGAZINE ARTICLE

Organ donor's surgery death sparks questions.

Cohen E. CNN. April 9, 2012.

AUDIOVISUAL

Limiting medical mistakes.

Maminta J. News 8 WTNH. February 3, 2012.

NEWSPAPER/MAGAZINE ARTICLE

Entire UPMC transplant team missed hepatitis alert.

Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.

STUDY

Applicability of Healthcare Failure Mode and Effects Analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments.

Linkin DR, Sausman C, Santos L, et al. Clin Infect Dis. 2005;41:1014-1019.

FACT SHEET/FAQS

Ensuring Correct Surgery.

Ann Arbor, MI: VA National Center for Patient Safety; 2006.

MULTI-USE WEBSITE

Hydraulic Fluid Facts.

Duke University Health System.

MULTI-USE WEBSITE

Strong for Surgery.

CERTAIN. Rockville, MD: Agency for Healthcare Research and Quality. SCOAP. Seattle, WA: Foundation for Health Care Quality.

NEWSPAPER/MAGAZINE ARTICLE

What surgeons leave behind costs some patients dearly.

Eisler P. USA Today. March 8, 2013.

COMMENTARY

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

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

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

NEWSPAPER/MAGAZINE ARTICLE

A towel with a safety message.

Lerner M. Minneapolis Star Tribune. January 25, 2009:B1.

NEWSPAPER/MAGAZINE ARTICLE

UTMC nurse tossed out kidney, ruined it. National experts say error is rare.

Messina I. Toledo Blade. August 24, 2012.

STUDY

Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center.

Bandari J, Schumacher K, Simon M, et al. Jt Comm J Qual Patient Saf. 2012;38:154-160.

NEWSPAPER/MAGAZINE ARTICLE

Personal best.

Gawande A. New Yorker. October 3, 2011.

NEWSPAPER/MAGAZINE ARTICLE

Preventing infections: how Portland hospitals compare.

Rojas-Burke J. The Oregonian. May 8, 2010.

NEWSPAPER/MAGAZINE ARTICLE

In just a flash, simple surgery can turn deadly.

Landro L. Wall Street Journal. February 18, 2009:D1.

FACT SHEET/FAQS

Tips for Safer Surgery.

Surgical Care Improvement Project.

AUDIOVISUAL

Checklist Manifesto author pairs simplicity with lifesaving.

Bowser BA. PBS News Hour. February 8, 2010.

MULTI-USE WEBSITE

Patient Safety First.

AORN, Inc., 2170 South Parker Rd, Suite 300, Denver, CO 80231-5711.

COMMENTARY

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

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

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