AHRQ Patient Safety Network

The Collection > Intraoperative Complications

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Intraoperative Complications

•Retained Surgical Instruments and Sponges (52)

•Wrong-Site Surgery (70)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (3)

Resource Types

•Clinical Guideline (3)

•Journal Article (114)

•Legislation/Regulation (3)

•Newspaper/Magazine Article (41)

•Special or Theme Issue (2)

•Tools/Toolkit (3)

•Web Resource (5)

Error Types

•Epidemiology of Errors and Adverse Events (48)

•Active Errors (76)

•Latent Errors (6)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (44)

•Legal and Policy Approaches (22)

•Error Reporting and Analysis (57)

•Communication Improvement (58)

•Human Factors Engineering (49)

•Teamwork (14)

•Specialization of Care (1)

•Logistical Approaches (4)

•Culture of Safety (12)

•Technologic Approaches (20)

•Education and Training (27)

Clinical Areas

Target Audience

•Health Care Providers (135)

•Health Care Executives and Administrators (115)

•Non-Health Care Professionals (32)

•Patients (42)

Setting of Care

•Hospitals (167)

•Psychiatric Facilities (1)

•Residential Facilities (1)

•Ambulatory Care (4)

•Outpatient Surgery (4)

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NEWSPAPER/MAGAZINE ARTICLE

'Wrong site' surgeries on the rise.

Davis R. USA Today. April 17, 2006.

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

When surgery goes wrong: weighing up the risks.

Feinmann J. The Independent. November 14, 2006.

STUDY

Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.

Hu YY, Arriaga AF, Roth EM, et al. Ann Surg. 2012;256:203-210.

COMMENTARY

Collegiality vs. Competence

Sagin T. AHRQ WebM&M [serial online]. March 2006.

REVIEW

Role of intraoperative cholangiography in avoiding bile duct injury.

Massarweh NN, Flum DR. J Am Coll Surg. 2007;204:656-664.

CLINICAL GUIDELINE

Practice Advisory on Intraoperative Awareness and Brain Function Monitoring.

ASA Task Force on Intraoperative Awareness and Brain Function Monitoring. Park Ridge, IL: American Society of Anesthesiologists; July 2005.

STUDY

When the bone flap hits the floor.

Jankowitz BT, Kondziolka DS. Neurosurgery. 2006;59:585-590.

NEWSPAPER/MAGAZINE ARTICLE

Surgery fires spur need for new guidelines.

Collins D. Associated Press [MSNBC]. July 26, 2007.

REVIEW

Spinal surgery and patient safety: a systems approach.

Wong DA. J Am Acad Orthop Surg. 2006;14:226-232.

NEWSPAPER/MAGAZINE ARTICLE

Wrong-site surgery.

Butcher L. Hosp Health Netw. November 2011.

STUDY

Surgical crisis management skills training and assessment: a stimulation-based approach to enhancing operating room performance.

Moorthy K, Munz Y, Forrest D, et al. Ann Surg. 2006;244:139-147.

COMMENTARY

Surgical count practice variability and the potential for retained surgical items.

Edel EM. AORN J. 2012;95:228-238.

STUDY

Tracking intraoperative complications.

Platz J, Hyman N. J Am Coll Surg. 2012;215:519-523.

NEWSPAPER/MAGAZINE ARTICLE

Clinic sued over towel left in patient.

McCarty JF. Plain Dealer. January 16, 2007:A1.

NEWSPAPER/MAGAZINE ARTICLE

The horror of awakening during surgery.

Foreman J. Boston Globe. February 8, 2005.

NEWSPAPER/MAGAZINE ARTICLE

Fires during surgeries a bigger risk than thought.

Kowalczyk L. Boston Globe. November 7, 2007;Health/Science section:1A.

NEWSPAPER/MAGAZINE ARTICLE

Airman fights for job after surgery mishap.

Hoffman M. Military Times. July 30, 2009.

NEWSPAPER/MAGAZINE ARTICLE

The day Joy died.

Brandeland GP. Med Econ. 2006 Oct 20;83:50, 52-53.

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