AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (21)

•Diagnostic Errors (78)

•Identification Errors (13)

•Discontinuities, Gaps, and Hand-Off Problems (46)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (177)

•Medical Complications (42)

•Nonsurgical Procedural Complications (13)

•Surgical Complications (100)

•Transfusion Complications (4)

•Psychological and Social Complications (24)

Origin/Sponsor

•Australia and New Zealand (12)

•North America (541)

Resource Types

•Audiovisual (6)

•Book/Report (26)

•Journal Article (515)

•Legislation/Regulation (3)

•Meeting/Conference (1)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (42)

•Press Release/Announcement (3)

•Special or Theme Issue (8)

•Tools/Toolkit (6)

•Web Resource (8)

Error Types

•Epidemiology of Errors and Adverse Events (263)

•Active Errors (87)

•Latent Errors (47)

•Near Miss (16)

Approach to Improving Safety
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Error Analysis

•Root Cause Analysis (23)

•Failure Mode Effects Analysis (18)

•Morbidity and Mortality Conferences (13)

•Narrative/Storytelling (7)

Clinical Areas

•Allied Health Services (2)

•Dentistry (1)

•Medicine (439)

•Nursing (43)

•Pharmacy (69)

Target Audience

•Health Care Providers (414)

•Health Care Executives and Administrators (467)

•Non-Health Care Professionals (172)

•Patients (32)

Setting of Care

•Hospitals (363)

•Psychiatric Facilities (1)

•Residential Facilities (9)

•Ambulatory Care (56)

•Outpatient Surgery (5)

•Patient Transport (2)

1 - 20 of 621

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SPECIAL OR THEME ISSUE

Patient Safety and the Invitational Conference on Contemporary Surgical Quality, Safety and Transparency.

Amer Surg. 2006;72:985-1149

ORGANIZATIONAL POLICY/GUIDELINES

Recommendations for quality assurance and improvement in surgical and autopsy pathology.

Association of Directors of Anatomic and Surgical Pathology. Hum Pathol. 2006;37:985-988.

SPECIAL OR THEME ISSUE

The Patient Safety in Surgery Study.

J Am Coll Surg. 2007;204(6):1087-1300.

STUDY

Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program.

Kiran RP, Ahmed Ali U, Coffey JC, Vogel JD, Pokala N, Fazio VW. Ann Surg. 2012;256:469-475.

REVIEW

Navigating towards improved surgical safety using aviation-based strategies.

Kao LS, Thomas EJ. J Surg Res. 2008;145:327-335.

STUDY

The American College of Surgeons' closed claims study: new insights for improving care.

Griffen FD, Stephens LS, Alexander JB, et al. J Am Coll Surg. 2007;204:561-569.

STUDY

Patient harm in general surgery--a prospective study.

Kaul AK, McCulloch PG. J Patient Saf. 2007;3:22-26.

STUDY

Time of day effects on the incidence of anesthetic adverse events.

Wright MC, Phillips-Bute B, Mark JB, et al. Qual Saf Health Care. 2006;15:258-263.

STUDY

Surgeon age and operative mortality in the United States.

Waljee JF, Greenfield LJ, Dimick JB, Birkmeyer JD. Ann Surg. 2006;244:353-362.

STUDY

Preventable morbidity at a mature trauma center.

Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144:536-541.

STUDY

Effectiveness of a community collaborative for eliminating the use of high-risk abbreviations written by physicians.

Leonhardt KK, Botticelli J. J Patient Saf. 2006;2:147-153.

STUDY

The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer.

Raab SS, Meier FA, Zarbo RJ, et al. J Clin Oncol. 2006;24:2808-2814.

STUDY

A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II.

Antonacci AC, Lam S, Lavarias V, Homel P, Eavey RA. J Surg Res. 2009;153:95-104.

STUDY

The impact of abbreviations on patient safety.

Brunetti L, Santell JP, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:576-583.

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.

MEASUREMENT TOOL/INDICATOR

The Physician Practice Patient Safety Assessment.

Medical Group Management Association Center for Research, Health Research and Educational Trust, Institute for Safe Medication Practices. 2005.

STUDY

Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians.

Davidenko JM, Snyder LS. J Electrocardiol. 2007;40:450-457.

REVIEW

Preventable errors in the operating room: retained foreign bodies after surgery--part I.

Gibbs VC, Coakley FD, Reines HD. Curr Probl Surg. 2007;44:281-337.

BOOK/REPORT

Quality and Safety in Women's Health Care. 2nd ed.

Women's Health Care Physicians; Committee on Patient Safety and Quality Improvement. Washington, DC: American College of Obstetricians and Gynecologists; 2010. ISBN: 9781934946930.

STUDY

Analysis of surgical errors in closed malpractice claims at 4 liability insurers.

Rogers SO Jr, Gawande AA, Kwaan M, Puopolo AL, Yoon C, Brennan TA, Studdert DM. Surgery. 2006;140:25-33.

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