AHRQ Patient Safety Network

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Identification Errors

•Wrong Patient (25)

•Wrong-Site Surgery (75)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (91)

•Legislation/Regulation (4)

•Meeting/Conference (1)

•Newsletter/Journal (2)

•Newspaper/Magazine Article (42)

•Special or Theme Issue (2)

•Tools/Toolkit (6)

•Web Resource (6)

Error Types

•Epidemiology of Errors and Adverse Events (45)

•Active Errors (60)

•Latent Errors (12)

•Near Miss (11)

Approach to Improving Safety

•Quality Improvement Strategies (59)

•Legal and Policy Approaches (16)

•Error Reporting and Analysis (53)

•Communication Improvement (77)

•Human Factors Engineering (45)

•Teamwork (18)

•Specialization of Care (2)

•Logistical Approaches (22)

•Culture of Safety (16)

•Technologic Approaches (29)

•Education and Training (28)

Clinical Areas

Target Audience

•Health Care Providers (114)

•Health Care Executives and Administrators (121)

•Non-Health Care Professionals (35)

•Patients (41)

Setting of Care

•Hospitals (120)

•Psychiatric Facilities (1)

•Residential Facilities (2)

•Ambulatory Care (10)

•Outpatient Surgery (11)

1 - 20 of 168

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STUDY

Surgical specimen identification errors: a new measure of quality in surgical care.

Makary MA, Epstein J, Pronovost PJ, Millman EA, Hartmann EC, Freischlag JA. Surgery. 2007;141:450-455.

COMMENTARY classic

Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand.

Ring DC, Herndon JH, Meyer GS. N Engl J Med. 2010;363:1950-1957.

NEWSPAPER/MAGAZINE ARTICLE

Preventing surgical errors.

Frenzel JC, Kelly T. HHN Magazine Online. January 6, 2009.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

BOOK/REPORT

Adverse Health Events in Minnesota: Ninth Annual Public Report.

St. Paul, MN: Minnesota Department of Health; January 2013.

COMMENTARY

Time out: an analysis.

Dillon KA. AORN J. 2008;88:437-442.

NEWSPAPER/MAGAZINE ARTICLE

Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.

Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.

COMMENTARY

Surgical site verification: A through Z.

Dunn D. J Perianesth Nurs. 2006;21:317-328.

ORGANIZATIONAL POLICY/GUIDELINES classic

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.

The Joint Commission.

NEWSPAPER/MAGAZINE ARTICLE

'Wrong site' surgeries on the rise.

Davis R. USA Today. April 17, 2006.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

NEWSPAPER/MAGAZINE ARTICLE

Hospital tells of surgery on wrong side.

Smith S. Boston Globe. July 4, 2008;Metro section:1A.

REVIEW

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.

COMMENTARY

The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited.

Stahel PF, Mehler PS, Clarke TJ, Varnell J. Patient Saf Surg. 2009;3:14.

NEWSPAPER/MAGAZINE ARTICLE

The wrong foot, and other tales of surgical error.

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

NEWSPAPER/MAGAZINE ARTICLE

When it's surgery, don't get it wrong.

Grant T. Washington Post. July 22, 2008:HE01

STUDY

Incidence, patterns, and prevention of wrong-site surgery.

Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.

STUDY

Surgical confusions in ophthalmology.

Simon JW, Ngo Y, Khan S, Strogatz D. Arch Ophthalmol. 2007;125:1515-1522.

NEWSPAPER/MAGAZINE ARTICLE

Get me out alive.

Feldman R. The Washington Post. May 2, 2006:HE01.

COMMENTARY

The Other Side.

Vincent C. AHRQ WebM&M [serial online]. October 2003.

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