AHRQ Patient Safety Network

The Collection > Audit and Feedback

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Safety Target

•Device-related Complications (11)

•Diagnostic Errors (19)

•Identification Errors (4)

•Discontinuities, Gaps, and Hand-Off Problems (26)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (75)

•Medical Complications (44)

•Nonsurgical Procedural Complications (8)

•Surgical Complications (33)

•Psychological and Social Complications (4)

Origin/Sponsor

•Asia (8)

•Australia and New Zealand (7)

Resource Types

•Journal Article (197)

•Newspaper/Magazine Article (15)

•Special or Theme Issue (3)

•Tools/Toolkit (3)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (82)

•Active Errors (52)

•Latent Errors (13)

•Near Miss (4)

Approach to Improving Safety
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Audit and Feedback

Clinical Areas

•Allied Health Services (1)

•Medicine (169)

•Nursing (13)

•Pharmacy (24)

Target Audience

•Health Care Providers (156)

•Health Care Executives and Administrators (218)

•Non-Health Care Professionals (76)

•Patients (4)

Setting of Care

•Hospitals (173)

•Residential Facilities (4)

•Ambulatory Care (19)

•Outpatient Surgery (4)

•Patient Transport (1)

1 - 20 of 230

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STUDY

Factors influencing incident reporting in surgical care.

Kreckler S, Catchpole K, McCulloch P, Handa A. Qual Saf Health Care. 2009;18:116-120.

STUDY

A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes.

Schraagen JM, Schouten T, Smit M, et al. BMJ Qual Saf. 2011;20:599-603.

STUDY

Detection of adverse events in surgical patients using the Trigger Tool approach.

Griffin FA, Classen DC. Qual Saf Health Care. 2008;17:253-258.

STUDY

Applying trigger tools to detect adverse events associated with outpatient surgery.

Rosen AK, Mull HJ, Kaafarani H, et al. J Patient Saf. 2011;7:45-59.

STUDY

Learning not to take it seriously: junior doctors' accounts of error.

Kroll L, Singleton A, Collier J, Rees Jones I. Med Educ. 2008;42:982-990.

STUDY

Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients.

Bilimoria KY, Kmiecik TE, DaRosa DA, et al. Arch Surg. 2009;144:305-311.

STUDY

Mapping changes in surgical mortality over 9 years by peer review audit.

Thompson AM, Ashraf Z, Burton H, Stonebridge PA. Br J Surg. 2005;92:1449-1452.

STUDY

Teamwork behaviours and errors during neonatal resuscitation.

Williams AL, Lasky RE, Dannemiller JL, Andrei AM, Thomas EJ. Qual Saf Health Care. 2010;19:60-64.

MULTI-USE WEBSITE

Scottish Audit of Surgical Mortality.

Royal College of Physicians and Surgeons of Glasgow, 232-242 St Vincent Street, Glasgow, UK G2 5RJ.

STUDY

Surgical skill is predicted by the ability to detect errors.

Bann S, Khan M, Datta V, Darzi A. Am J Surg. 2005;189:412-415.

STUDY

Nature, causes and consequences of unintended events in surgical units.

van Wagtendonk I, Smits M, Merten H, Heetveld MJ, Wagner C. Br J Surg. 2010;97:1730-1740.

STUDY

Optimising surgical training: use of feedback to reduce errors during a simulated surgical procedure.

Boyle E, Al-Akash M, Gallagher AG, Traynor O, Hill AD, Neary PC. Postgrad Med J. 2011;87:524-528.

STUDY

Resident participation does not affect surgical outcomes, despite introduction of new techniques.

Patel SP, Gauger PG, Brown DL, Englesbe MJ, Cederna PS. J Am Coll Surg. 2010;211:540-545.

STUDY

Patient characteristics and the occurrence of never events.

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

STUDY

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.

BOOK/REPORT

An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.

Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.

STUDY

Methodology and bias in assessing compliance with a surgical safety checklist.

Poon SJ, Zuckerman SL, Mainthia R, et al. Jt Comm J Qual Patient Saf. 2013;39:77-82.

STUDY

Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study.

Paine LA, Rosenstein BJ, Sexton JB, Kent P, Holzmueller CG, Pronovost PJ. Qual Saf Health Care. 2010;19:547-554.

STUDY

Designing and implementing a comprehensive quality and patient safety management model: a paradigm for perioperative improvement.

Herzer KR, Mark LJ, Michelson JD, Saletnik LA, Lundquist CA. J Patient Saf. 2008;4:84-92.

COMMENTARY

What Can the Rest of the Health Care System Learn from the VA’s Quality and Safety Transformation?

Jha AK. AHRQ WebM&M [serial online]. September 2006.

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