AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (29)

•Diagnostic Errors (24)

•Identification Errors (79)

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

•Fatigue and Sleep Deprivation (31)

•Medication Safety (60)

•Medical Complications (65)

•Nonsurgical Procedural Complications (9)

•Surgical Complications (681)

•Transfusion Complications (3)

•Psychological and Social Complications (43)

Origin/Sponsor

•Australia and New Zealand (18)

•Central and South America (1)

•Europe (161)

•North America (642)

Resource Types

•Audiovisual (9)

•Book/Report (21)

•Clinical Guideline (4)

•Journal Article (668)

•Legislation/Regulation (10)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (96)

•Press Release/Announcement (2)

•Special or Theme Issue (10)

•Tools/Toolkit (12)

•Web Resource (19)

Error Types

•Epidemiology of Errors and Adverse Events (205)

•Active Errors (174)

•Latent Errors (55)

•Near Miss (20)

Approach to Improving Safety

•Quality Improvement Strategies (188)

•Legal and Policy Approaches (64)

•Error Reporting and Analysis (225)

•Communication Improvement (263)

•Human Factors Engineering (189)

•Teamwork (147)

•Specialization of Care (23)

•Logistical Approaches (58)

•Culture of Safety (92)

•Technologic Approaches (85)

•Education and Training (209)

Clinical Areas
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Surgery

•Cardiothoracic Surgery (27)

•General Surgery (47)

•Neurosurgery (19)

•Otolaryngology (12)

•Orthopedic Surgery (25)

•Pediatric Surgery (31)

•Plastic Surgery (14)

•Surgical Oncology (9)

•Vascular Surgery (9)

Target Audience

•Health Care Providers (636)

•Health Care Executives and Administrators (596)

•Non-Health Care Professionals (254)

•Patients (95)

Setting of Care

•Hospitals (753)

•Residential Facilities (2)

•Ambulatory Care (16)

•Outpatient Surgery (48)

•Patient Transport (4)

1 - 20 of 854

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STUDY

classic

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.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

SPECIAL OR THEME ISSUE

Patient Safety.

Martin RF, Sanchez JA, eds. Surg Clin North Am. 2012;92:1-177.

COMMENTARY

How long does it take to train a surgeon?

Purcell Jackson G, Tarpley JL. BMJ. 2009;339:b4260.

BOOK/REPORT

Safe Surgery Guide.

Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404073.

STUDY

classic

A surgical safety checklist to reduce morbidity and mortality in a global population.

Haynes AB, Weiser TG, Berry WR, et al; for the Safe Surgery Saves Lives Study Group. N Engl J Med. 2009;360:491-499.

STUDY

How does patient safety culture in the operating room and post-anesthesia care unit compare to the rest of the hospital?

Kaafarani HM, Itani KM, Rosen AK, Zhao S, Hartmann CW, Gaba DM. Am J Surg. 2009;198:70-75.

STUDY

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

Sexton JB, Makary MA, Tersigni AR, et al. Anesthesiology. 2006;105:877-884.

COMMENTARY

Briefings, checklists, geese, and surgical safety.

Karl R. Ann Surg Oncol. 2010;17:8-11.

COMMENTARY

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

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

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.

NEWSPAPER/MAGAZINE ARTICLE

The day Joy died.

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

MULTI-USE WEBSITE

Safe Surgery 2015.

Harvard School of Public Health.

STUDY

Integrating incident reporting into an electronic patient record system.

Haller G, Myles PS, Stoelwinder J, Langley M, Anderson H, McNeil J. J Am Med Inform Assoc. 2007;14:175-181.

ORGANIZATIONAL POLICY/GUIDELINES

Practice advisory for the prevention and management of operating room fires.

Caplan RA, Barker SJ, Connis RT, et al; for American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology. 2008;108:786-801.

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.

COMMENTARY

Checklists and guidelines: imaging techniques for visualizing what to do.

Davidoff F. JAMA. 2010;304:206-207.

COMMENTARY

The top 10 list for a safe and effective sign-out.

Kemp CD, Bath JM, Berger J, et al. Arch Surg. 2008;143:1008-1010.

STUDY

Implementing a pre-operative checklist to increase patient safety: a 1-year follow-up of personnel attitudes.

Nilsson L, Lindberget O, Gupta A, Vegfors M. Acta Anaesthesiol Scand. 2010;54:176-182.

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