AHRQ Patient Safety Network

The Collection > Surgery

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Safety Target

•Device-related Complications (21)

•Diagnostic Errors (19)

•Identification Errors (71)

•Discontinuities, Gaps, and Hand-Off Problems (59)

•Fatigue and Sleep Deprivation (27)

•Medication Safety (51)

•Medical Complications (35)

•Nonsurgical Procedural Complications (7)

•Surgical Complications (573)

•Transfusion Complications (1)

•Psychological and Social Complications (37)

Origin/Sponsor

•Asia (10)

•Australia and New Zealand (18)

Resource Types

•Clinical Guideline (4)

•Journal Article (585)

•Legislation/Regulation (10)

•Meeting/Conference (1)

•Newspaper/Magazine Article (61)

•Press Release/Announcement (1)

•Special or Theme Issue (10)

•Tools/Toolkit (12)

•Web Resource (16)

Error Types

•Epidemiology of Errors and Adverse Events (179)

•Active Errors (146)

•Latent Errors (46)

•Near Miss (21)

Approach to Improving Safety

•Quality Improvement Strategies (167)

•Legal and Policy Approaches (40)

•Error Reporting and Analysis (182)

•Communication Improvement (228)

•Human Factors Engineering (169)

•Teamwork (133)

•Specialization of Care (16)

•Logistical Approaches (44)

•Culture of Safety (75)

•Technologic Approaches (69)

•Education and Training (165)

Clinical Areas
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Surgery

•Cardiothoracic Surgery (16)

•General Surgery (29)

•Neurosurgery (14)

•Otolaryngology (4)

•Orthopedic Surgery (16)

•Pediatric Surgery (18)

•Plastic Surgery (8)

•Surgical Oncology (4)

•Urology (5)

•Vascular Surgery (6)

Target Audience

•Health Care Providers (557)

•Health Care Executives and Administrators (528)

•Non-Health Care Professionals (207)

•Patients (55)

Setting of Care

•Hospitals (660)

•Residential Facilities (1)

•Ambulatory Care (7)

•Outpatient Surgery (30)

•Patient Transport (2)

1 - 20 of 717

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STUDY

Analysis of errors enacted by surgical trainees during skills training courses.

Tang B, Hanna GB, Cuschieri A. Surgery. 2005;138:14-20.

STUDY

"First, do no harm": balancing competing priorities in surgical practice.

Leung A, Luu S, Regehr G, Murnaghan ML, Gallinger S, Moulton CA. Acad Med. 2012;87:1368-1374.

COMMENTARY

Use of the common gas outlet for supplementary oxygen during Caesarean section.

Edsell ME, Erasmus PD. Anaesthesia. 2005;60:1152-1153.

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.

COMMENTARY

Surgical accountability in the 1880s: the death of Susan Nixon.

Watters GR, Walker DR. ANZ J Surg. 2005;75:719-722.

COMMENTARY

Lap Burn.

Ball K. AHRQ WebM&M [serial online]. October 2004.

COMMENTARY

Right? Left? Neither!

Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.

STUDY

Failures in communication and information transfer across the surgical care pathway: interview study.

Nagpal K, Arora S, Vats A, et al. BMJ Qual Saf. 2012;21:843-849.

REVIEW

The role of practice guidelines and evidence-based medicine in perioperative patient safety.

Crosby E. Can J Anaesth. 2013;60:143-151.

STUDY

Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.

Hu YY, Arriaga AF, Roth EM, et al. Ann Surg. 2012;256:203-210.

STUDY

Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR.

Lingard L, Espin S, Rubin B, et al. Qual Saf Health Care. 2005;14:340-346.

MULTI-USE WEBSITE

Surgical Care Improvement Project.

National SCIP Partnership, Oklahoma Foundation for Medical Quality, 14000 Quail Springs Parkway, Suite 400, Oklahoma City, OK, 73134.

STUDY

Realistic distractions and interruptions that impair simulated surgical performance by novice surgeons.

Feuerbacher RL, Funk KH, Spight DH, Diggs BS, Hunter JG. Arch Surg. 2012;147:1026-1030.

COMMENTARY

The lost sponge: patient safety in the operating room.

Grant-Orser A, Davies P, Singh SS. CMAJ. 2012;184:1275-1278.

STUDY

Effect of short-term pretrial practice on surgical proficiency in simulated environments: a randomized trial of the "preoperative warm-up" effect.

Kahol K, Satava RM, Ferrara J, Smith ML. J Am Coll Surg. 2009;208:255-268.

REVIEW

Communication devices in the operating room.

Ruskin KJ. Curr Opin Anaesthesiol. 2006;19:655-659.

BOOK/REPORT

Reducing Colorectal Surgical Site Infections.

Oakbrook Terrace, IL: Joint Commission Center for Transforming Health Care. Chicago, IL: American College of Surgeons. November 2012.

STUDY

Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology.

Macario A, Morris D, Morris S. Arch Surg. 2006;141:659-662.

ORGANIZATIONAL POLICY/GUIDELINES

Statement on the prevention of retained foreign bodies after surgery.

Bulletin of the American College of Surgeons; October 2005.

COMMENTARY

Wrong site surgery.

Fraser SG, Adams W. Br J Ophthalmol. 2006;90:814-816.

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