AHRQ Patient Safety Network

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•Device-related Complications (21)

•Diagnostic Errors (18)

•Identification Errors (56)

•Discontinuities, Gaps, and Hand-Off Problems (52)

•Fatigue and Sleep Deprivation (29)

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•Medical Complications (58)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (583)

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Error Types

•Epidemiology of Errors and Adverse Events (166)

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Approach to Improving Safety

•Quality Improvement Strategies (157)

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Clinical Areas
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Surgery

•Cardiothoracic Surgery (19)

•General Surgery (27)

•Neurosurgery (10)

•Otolaryngology (7)

•Orthopedic Surgery (17)

•Pediatric Surgery (19)

•Plastic Surgery (14)

•Surgical Oncology (6)

•Urology (4)

•Vascular Surgery (5)

Target Audience

•Health Care Providers (516)

•Health Care Executives and Administrators (500)

•Non-Health Care Professionals (205)

•Patients (95)

Setting of Care

•Hospitals (625)

•Residential Facilities (2)

•Ambulatory Care (13)

•Outpatient Surgery (40)

•Patient Transport (2)

1 - 20 of 719

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BOOK/REPORT

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

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

NEWSPAPER/MAGAZINE ARTICLE

Saving lives: hospitals have signed on to a six-part plan to avoid a multitude of unnecessary deaths.

Comarow A. US News & World Report. July 18, 2005;139:74,76,79.

NEWSPAPER/MAGAZINE ARTICLE

Get me out alive.

Feldman R. The Washington Post. May 2, 2006:HE01.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

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

STUDY

Surgical training, duty-hour restrictions, and implications for meeting the Accreditation Council for Graduate Medical Education core competencies: views of surgical interns compared with program directors.

Antiel RM, Van Arendonk KJ, Reed DA, et al. Arch Surg. 2012;147:536-541.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2013.

STUDY

The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients.

Encinosa WE, Hellinger FJ. Health Serv Res. 2008;43:2067-2085.

NEWSPAPER/MAGAZINE ARTICLE

Avoidable mistakes rise despite hospital efforts.

Colliver V. San Francisco Chronicle. June 2, 2010;A1.

COMMENTARY

Resident duty hours in surgery for ensuring patient safety, providing optimum resident education and training, and promoting resident well-being: a response from the American College of Surgeons to the Report of the Institute of Medicine, "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety."

Britt LD, Sachdeva AK, Healy GB, Whalen TV, Blair PG; Members of the ACS Task Force on Resident Duty Hours. Surgery. 2009;146:398-409.

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.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

MULTI-USE WEBSITE

Safe Surgery 2015.

Harvard School of Public Health.

COMMENTARY

The impact of professionalism on safe surgical care.

Whittemore AD. J Vasc Surg. 2007;45:415-419.

COMMENTARY

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

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

STUDY

The $17.1 billion problem: the annual cost of measurable medical errors.

Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. Health Aff (Millwood). 2011;30:596-603.

BOOK/REPORT classic

The Checklist Manifesto: How to Get Things Right.

Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.

BOOK/REPORT

Better: A Surgeon's Notes on Performance.

Gawande A. New York, NY: Metropolitan Books; 2007. ISBN: 0805082115.

NEWSPAPER/MAGAZINE ARTICLE

Entire UPMC transplant team missed hepatitis alert.

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

COMMENTARY

Disclosing harmful medical errors to patients: tackling three tough cases.

Gallagher TH, Bell SK, Smith KM, Mello MM, McDonald TB. Chest. 2009;136:897-903.

STUDY

Needlestick injuries among surgeons in training.

Makary MA, Al-Attar A, Holzmueller CG, et al. N Engl J Med. 2007;356:2693-2699.

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