AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (29)

•Diagnostic Errors (26)

•Identification Errors (70)

•Discontinuities, Gaps, and Hand-Off Problems (74)

•Fatigue and Sleep Deprivation (29)

•Medication Safety (65)

•Medical Complications (66)

•Nonsurgical Procedural Complications (10)

•Surgical Complications (648)

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•Psychological and Social Complications (40)

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•Africa (2)

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•Clinical Guideline (3)

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•Newspaper/Magazine Article (85)

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•Special or Theme Issue (11)

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Error Types

•Epidemiology of Errors and Adverse Events (204)

•Active Errors (161)

•Latent Errors (50)

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Approach to Improving Safety

•Quality Improvement Strategies (189)

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•Error Reporting and Analysis (218)

•Communication Improvement (247)

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•Culture of Safety (95)

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•Education and Training (201)

Clinical Areas
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Surgery

•Cardiothoracic Surgery (26)

•General Surgery (41)

•Neurosurgery (14)

•Otolaryngology (13)

•Orthopedic Surgery (24)

•Pediatric Surgery (29)

•Plastic Surgery (15)

•Surgical Oncology (11)

•Urology (8)

•Vascular Surgery (6)

Target Audience

•Health Care Providers (612)

•Health Care Executives and Administrators (593)

•Non-Health Care Professionals (241)

•Patients (84)

Setting of Care

•Hospitals (721)

•Residential Facilities (2)

•Ambulatory Care (18)

•Outpatient Surgery (47)

•Patient Transport (2)

1 - 20 of 824

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BOOK/REPORT

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

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

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

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

STUDY

Infection control assessment of ambulatory surgical centers.

Schaefer MK, Jhung M, Dahl M, et al. JAMA. 2010;303:2273-2279.

COMMENTARY

Reducing surgical complications.

Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:660-665.

BOOK/REPORT classic

The Checklist Manifesto: How to Get Things Right.

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

COMMENTARY

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

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

COMMENTARY

Staggered Sensitivity Results

Guglielmo BJ. AHRQ WebM&M [serial online]. March 2007.

MULTI-USE WEBSITE

Council on Surgical and Perioperative Safety.

Council on Surgical and Perioperative Safety; 633 N. St. Clair St. Chicago, IL, 60611.

BOOK/REPORT

2009 National Healthcare Quality Report.

Rockville, MD: Agency for Healthcare Research and Quality; March 2010. AHRQ Publication No. 10-0003.

MULTI-USE WEBSITE

Standardization Projects.

Washington State Hospital Association.

STUDY

Assessment of latent factors contributing to error: addressing surgical pathology error wisely.

Smith ML, Raab SS. Arch Pathol Lab Med. 2011;135:1436-1440.

COMMENTARY

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

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

STUDY

Patient characteristics and the occurrence of never events.

Fry DE, Pine M, Jones BL, Meimban RJ. Arch Surg. 2010;145:148-151.

BOOK/REPORT

Patient Safety Authority Annual Reports.

Harrisburg, PA: Patient Safety Authority; April 2012.

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.

COMMENTARY

Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy.

Bellandi T, Albolino S, Tartaglia R, Filipponi F. Transplant Proc. 2010;42:2187-2189.

COMMENTARY

Surgical team training: promoting high reliability with nontechnical skills.

Paige JT. Surg Clin North Am. 2010;90:569-581.

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

Lost surgical specimens, lost opportunities.

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

REVIEW

Detecting adverse events in dermatologic surgery.

Pinney D, Pearce DJ, Feldman SR. Dermatol Surg. 2010;36:8-14.

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