AHRQ Patient Safety Network

The Collection > Surgery

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Safety Target

•Device-related Complications (22)

•Diagnostic Errors (23)

•Identification Errors (62)

•Discontinuities, Gaps, and Hand-Off Problems (62)

•Fatigue and Sleep Deprivation (33)

•Medication Safety (52)

•Medical Complications (50)

•Nonsurgical Procedural Complications (8)

•Surgical Complications (613)

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•Africa (2)

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•Clinical Guideline (4)

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Error Types

•Epidemiology of Errors and Adverse Events (178)

•Active Errors (143)

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•Near Miss (18)

Approach to Improving Safety

•Quality Improvement Strategies (171)

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•Error Reporting and Analysis (199)

•Communication Improvement (239)

•Human Factors Engineering (165)

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•Specialization of Care (24)

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•Technologic Approaches (68)

•Education and Training (194)

Clinical Areas
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Surgery

•Cardiothoracic Surgery (23)

•General Surgery (34)

•Neurosurgery (14)

•Otolaryngology (6)

•Orthopedic Surgery (21)

•Pediatric Surgery (17)

•Plastic Surgery (14)

•Surgical Oncology (4)

•Urology (7)

•Vascular Surgery (4)

Target Audience

•Health Care Providers (575)

•Health Care Executives and Administrators (531)

•Non-Health Care Professionals (228)

•Patients (82)

Setting of Care

•Hospitals (667)

•Residential Facilities (1)

•Ambulatory Care (15)

•Outpatient Surgery (39)

•Patient Transport (2)

1 - 20 of 770

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STUDY

Causes of near misses: perceptions of perioperative nurses.

Cohoon B. AORN J. 2011;93:551-565.

COMMENTARY

"Managing up" can improve teamwork in the OR.

Smith SL. AORN J. 2010;91:576-582.

STUDY

Observational assessment of surgical teamwork: a feasibility study.

Undre S, Healey AN, Darzi A, Vincent CA. World J Surg. 2006;30:1774-1783.

NEWSPAPER/MAGAZINE ARTICLE

Costly issues of an uncommunicative OR.

Neil R. Mat Manage Health Care. March 2006;15:30-33.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

STUDY

Action research, simulation, team communication, and bringing the tacit into voice. Society for Simulation in Healthcare.

Forsythe L. Simul Healthc. 2009;4:143-148.

COMMENTARY

The normalization of deviance: what are the perioperative risks?

McNamara SA. AORN J. 2011;93:796-801.

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.

STUDY

Communication practices on 4 Harvard surgical services: a surgical safety collaborative.

ElBardissi AW, Regenbogen SE, Greenberg CC, et al. Ann Surg. 2009;250:861-865.

COMMENTARY

A common body of care: the ethics and politics of teamwork in the operating theater are inseparable.

Bleakley A. J Med Philos. 2006;31:305-322.

STUDY

Error, stress, and teamwork in medicine and aviation: cross sectional surveys.

Sexton JB, Thomas EJ, Helmreich RL. BMJ. 2000;320:745-749.

COMMENTARY

A team training program using human factors to enhance patient safety.

Marshall DA, Manus DA. AORN J. 2007;86:994-1011.

COMMENTARY

Communication in the perioperative setting.

Cvetic E. AORN J. 2011;94:261-270.

STUDY

Interruptions and miscommunications in surgery: an observational study.

Gillespie BM, Chaboyer W, Fairweather N. AORN J. 2012;95:576-590.

MULTI-USE WEBSITE

National Time Out Day.

AORN Patient Safety First.

STUDY

Bridging the communication gap in the operating room with medical team training.

Awad SS, Fagan SP, Bellows C, et al. Am J Surg. 2005;190:770-774.

STUDY

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.

NEWSPAPER/MAGAZINE ARTICLE

Tomorrow's operating room to harness Net, RFID.

Olsen S. CNET News.com; October 19, 2005.

TOOLKIT

Perioperative Patient 'Hand-Off' Tool Kit.

Association of Perioperative Registered Nurses.

COMMENTARY

Defining the technical skills of teamwork in surgery.

Healey AN, Undre S, Vincent CA. Qual Saf Health Care. 2006;15:231-234.

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