AHRQ Patient Safety Network

The Collection > Communication between Providers

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Safety Target

•Device-related Complications (18)

•Diagnostic Errors (44)

•Identification Errors (61)

•Discontinuities, Gaps, and Hand-Off Problems (289)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (234)

•Medical Complications (55)

•Nonsurgical Procedural Complications (15)

•Surgical Complications (196)

•Transfusion Complications (2)

•Psychological and Social Complications (52)

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•Clinical Guideline (1)

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•Newspaper/Magazine Article (112)

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•Special or Theme Issue (18)

•Tools/Toolkit (13)

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Error Types

•Epidemiology of Errors and Adverse Events (134)

•Active Errors (169)

•Latent Errors (75)

•Near Miss (18)

Approach to Improving Safety
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Communication between Providers

•Read Back Protocols (89)

•Structured Hand-offs (89)

•SBAR (20)

•Medication Reconciliation (119)

Clinical Areas

•Allied Health Services (4)

•Medicine (652)

•Nursing (97)

•Pharmacy (99)

Target Audience

•Health Care Providers (692)

•Health Care Executives and Administrators (649)

•Non-Health Care Professionals (287)

•Patients (52)

Setting of Care

•Hospitals (615)

•Psychiatric Facilities (3)

•Residential Facilities (23)

•Ambulatory Care (87)

•Outpatient Surgery (11)

•Patient Transport (13)

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AWARD RECIPIENT

2006 Quest for Quality Prize.

Runy LA. Hosp Health Netw. September 2006.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

BOOK/REPORT classic

Safe Practices for Better Healthcare—2010 Update.

National Quality Forum. Washington, DC: National Quality Forum; 2010.

NEWSPAPER/MAGAZINE ARTICLE

In just a flash, simple surgery can turn deadly.

Landro L. Wall Street Journal. February 18, 2009:D1.

STUDY

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

Makary MA, Sexton JB, Freischlag JA, et al. J Am Coll Surg. 2006;202:746-752.

COMMENTARY

Video technology to advance safety in the operating room and perioperative environment.

Xiao Y, Schimpff S, Mackenzie C, et al. Surg Innov. 2007;14:52-61.

STUDY

Speaking across the drapes: communication strategies of anesthesiologists and obstetricians during a simulated maternal crisis.

Minehart RD, Pian-Smith MC, Walzer TB, et al. Simul Healthc. 2012;7:166-170.

STUDY

Failure to rescue as a process measure to evaluate fetal safety during labor.

Beaulieu MJ. MCN Am J Matern Child Nurs. 2009;34:18-23.

REVIEW

Teamwork in obstetric critical care.

Guise JM, Segel S. Best Pract Res Clin Obstet Gynaecol. 2008;22:937-951.

REVIEW

The case for simulation as part of a comprehensive patient safety program.

Argani CH, Eichelberger M, Deering S, Satin AJ. Am J Obstet Gynecol. 2012;206:451-455.

STUDY

A novel method for reproducibly measuring the effects of interventions to improve emotional climate, indices of team skills and communication, and threat to patient outcome in a high-volume thoracic surgery center.

Nurok M, Lipsitz S, Satwicz P, Kelly A, Frankel A. Arch Surg. 2010;145:489-495.

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

Failure to Latch

Rodriguez M., Mannel R., Frye D. MN AHRQ WebM&M [serial online]. September 2008.

STUDY

Improving operating room safety.

Hurlbert SN, Garrett J. Patient Saf Surg. 2009;3:25.

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

Health care workers as second victims of medical errors.

Edrees HH, Paine LA, Feroli ER, Wu AW. Pol Arch Med Wewn. 2011;121:101-108.

REVIEW

Intimidation: a concept analysis.

Lamontagne C. Nurs Forum. 2010;45:54-65.

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.

STUDY

Content analysis of team communication in an obstetric emergency scenario.

Siassakos D, Draycott T, Montague I, Harris M. J Obstet Gynaecol. 2009;29:499-503.

NEWSPAPER/MAGAZINE ARTICLE

Tomorrow's operating room to harness Net, RFID.

Olsen S. CNET News.com; October 19, 2005.

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