AHRQ Patient Safety Network

The Collection > Surgery

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Safety Target

•Device-related Complications (27)

•Diagnostic Errors (23)

•Identification Errors (79)

•Discontinuities, Gaps, and Hand-Off Problems (68)

•Fatigue and Sleep Deprivation (28)

•Medication Safety (57)

•Medical Complications (59)

•Nonsurgical Procedural Complications (8)

•Surgical Complications (672)

•Transfusion Complications (2)

•Psychological and Social Complications (43)

Origin/Sponsor

•Africa (2)

•Asia (10)

•Australia and New Zealand (17)

•Central and South America (1)

Resource Types

•Clinical Guideline (4)

•Journal Article (644)

•Legislation/Regulation (10)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (96)

•Press Release/Announcement (2)

•Special or Theme Issue (9)

•Tools/Toolkit (12)

•Web Resource (19)

Error Types

•Epidemiology of Errors and Adverse Events (196)

•Active Errors (175)

•Latent Errors (51)

•Near Miss (21)

Approach to Improving Safety

•Quality Improvement Strategies (187)

•Legal and Policy Approaches (62)

•Error Reporting and Analysis (216)

•Communication Improvement (260)

•Human Factors Engineering (186)

•Teamwork (145)

•Specialization of Care (23)

•Logistical Approaches (53)

•Culture of Safety (90)

•Technologic Approaches (76)

•Education and Training (208)

Clinical Areas
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Surgery

•Cardiothoracic Surgery (23)

•General Surgery (44)

•Neurosurgery (17)

•Otolaryngology (9)

•Orthopedic Surgery (23)

•Pediatric Surgery (28)

•Plastic Surgery (14)

•Surgical Oncology (7)

•Urology (9)

•Vascular Surgery (5)

Target Audience

•Health Care Providers (610)

•Health Care Executives and Administrators (568)

•Non-Health Care Professionals (245)

•Patients (95)

Setting of Care

•Hospitals (728)

•Residential Facilities (1)

•Ambulatory Care (14)

•Outpatient Surgery (47)

•Patient Transport (3)

1 - 20 of 829

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NEWSPAPER/MAGAZINE ARTICLE

A pinpoint beam strays invisibly, harming instead of healing.

Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.

AUDIOVISUAL

Limiting medical mistakes.

Maminta J. News 8 WTNH. February 3, 2012.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

STUDY

Risks of complications by attending physicians after performing nighttime procedures.

Rothschild JM, Keohane CA, Rogers S, et al. JAMA. 2009;302:1565-1572.

NEWSPAPER/MAGAZINE ARTICLE

The wrong foot, and other tales of surgical error.

Altman LK. New York Times. December 11, 2001;1:1.

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.

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.

NEWSPAPER/MAGAZINE ARTICLE

The pain of wrong site surgery.

Boodman SG. Washington Post. June 21, 2011:E1.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

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

NEWSPAPER/MAGAZINE ARTICLE

Entire UPMC transplant team missed hepatitis alert.

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

STUDY

The introduction of a surgical safety checklist in a tertiary referral obstetric centre.

Kearns RJ, Uppal V, Bonner J, Robertson J, Daniel M, McGrady EM. BMJ Qual Saf. 2011;20:818-822.

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

"Managing up" can improve teamwork in the OR.

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

NEWSPAPER/MAGAZINE ARTICLE

A towel with a safety message.

Lerner M. Minneapolis Star Tribune. January 25, 2009:B1.

ORGANIZATIONAL POLICY/GUIDELINES

Safe Site Invasive Procedure—Non-Operating Room.

Bloomington, MN: Institute for Clinical Systems Improvement; 2010.

COMMENTARY

Reducing surgical complications.

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

NEWSPAPER/MAGAZINE ARTICLE

Robotic surgery: how safe is it?

Quintero F. Orlando Sentinel. June 16, 2010;A1.

COMMENTARY

Retained surgical items and minimally invasive surgery.

Gibbs VC. World J Surg. 2011;35:1532-1539.

STUDY

Interruptions and miscommunications in surgery: an observational study.

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

STUDY

Causes of near misses: perceptions of perioperative nurses.

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

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