AHRQ Patient Safety Network

The Collection > Surgery

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Safety Target

•Device-related Complications (31)

•Diagnostic Errors (27)

•Identification Errors (73)

•Discontinuities, Gaps, and Hand-Off Problems (71)

•Fatigue and Sleep Deprivation (29)

•Medication Safety (67)

•Medical Complications (57)

•Nonsurgical Procedural Complications (8)

•Surgical Complications (654)

•Transfusion Complications (2)

•Psychological and Social Complications (41)

Origin/Sponsor

•Africa (2)

•Asia (11)

•Australia and New Zealand (17)

•Central and South America (1)

Resource Types

•Clinical Guideline (3)

•Journal Article (645)

•Legislation/Regulation (10)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (91)

•Press Release/Announcement (2)

•Special or Theme Issue (10)

•Tools/Toolkit (12)

•Web Resource (17)

Error Types

•Epidemiology of Errors and Adverse Events (206)

•Active Errors (168)

•Latent Errors (55)

•Near Miss (21)

Approach to Improving Safety

•Quality Improvement Strategies (183)

•Legal and Policy Approaches (57)

•Error Reporting and Analysis (233)

•Communication Improvement (247)

•Human Factors Engineering (192)

•Teamwork (139)

•Specialization of Care (26)

•Logistical Approaches (56)

•Culture of Safety (95)

•Technologic Approaches (79)

•Education and Training (194)

Clinical Areas
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Surgery

•Cardiothoracic Surgery (23)

•General Surgery (41)

•Neurosurgery (18)

•Otolaryngology (11)

•Orthopedic Surgery (27)

•Pediatric Surgery (28)

•Plastic Surgery (14)

•Surgical Oncology (9)

•Urology (8)

•Vascular Surgery (7)

Target Audience

•Health Care Providers (600)

•Health Care Executives and Administrators (598)

•Non-Health Care Professionals (238)

•Patients (85)

Setting of Care

•Hospitals (716)

•Residential Facilities (2)

•Ambulatory Care (16)

•Outpatient Surgery (45)

•Patient Transport (3)

1 - 20 of 822

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REVIEW

Nature of human error: implications for surgical practice.

Cuschieri A. Ann Surg. 2006;244:642-648.

BOOK/REPORT

Annual Benchmarking Report: Malpractice Risks in Surgery.

Cambridge, MA: CRICO/RMF Strategies; 2010.

NEWSPAPER/MAGAZINE ARTICLE

Lost surgical specimens, lost opportunities.

PA-PSRS Patient Saf Advis. September 2005;2:1-5.

STUDY

Nature, causes and consequences of unintended events in surgical units.

van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Br J Surg. 2010;97:1730-1740.

STUDY

Preprinted order sets as a safety intervention in pediatric sedation.

Broussard M, Bass PF 3rd, Arnold CL, McLarty JW, Bocchini JA Jr. J Pediatr. 2009;154:865-868.

STUDY

Time of day effects on the incidence of anesthetic adverse events.

Wright MC, Phillips-Bute B, Mark JB, et al. Qual Saf Health Care. 2006;15:258-263.

COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

NEWSPAPER/MAGAZINE ARTICLE

Fatal outcome after inadvertent injection of topical epinephrine.

ISMP Medication Safety Alert! Acute Care Edition. March 26, 2009;14:1-2.

STUDY

Classification of adverse events occurring in a surgical intensive care unit.

Frankel H, Sperry J, Kaplan L, Foley A, Rabinovici R. Am J Surg. 2007;194:328-332.

STUDY

Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.

Kaplan LJ, Maerz LL, Schuster K, et al. J Trauma. 2009;67:173-179.

STUDY

Relationship between patient complaints and surgical complications.

Murff HJ, France DJ, Blackford J, et al. Qual Saf Health Care. 2006;15:13-16.

COMMENTARY

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

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

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.

STUDY

A system analysis of a suboptimal surgical experience.

Lee RC, Cooke DL, Richards M. Patient Saf Surg. 2009;3:1.

STUDY

Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program.

Kiran RP, Ahmed Ali U, Coffey JC, Vogel JD, Pokala N, Fazio VW. Ann Surg. 2012;256:469-475.

STUDY

Retained surgical items: a problem yet to be solved.

Stawicki SP, Moffatt-Bruce SD, Ahmed HM, et al. J Am Coll Surg. 2013;216:15-22.

REVIEW

Navigating towards improved surgical safety using aviation-based strategies.

Kao LS, Thomas EJ. J Surg Res. 2008;145:327-335.

REVIEW

Avoiding wrong site surgery: a systematic review.

DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.

STUDY

Incorrect surgical counts: a qualitative analysis.

Rowlands A, Steeves R. AORN J. 2010;92:410-419.

STUDY

Quantifying and characterizing adverse events in dermatologic surgery.

O'Neill JL, Lee YS, Solomon JA, et al. Dermatol Surg. 2013 Mar 6; [Epub ahead of print].

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