AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (14)

•Diagnostic Errors (27)

•Identification Errors (63)

•Discontinuities, Gaps, and Hand-Off Problems (189)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (146)

•Medical Complications (44)

•Nonsurgical Procedural Complications (11)

•Surgical Complications (200)

•Transfusion Complications (2)

•Psychological and Social Complications (46)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (12)

Resource Types

•Clinical Guideline (1)

•Journal Article (483)

•Legislation/Regulation (12)

•Meeting/Conference (2)

•Newspaper/Magazine Article (99)

•Special or Theme Issue (13)

•Tools/Toolkit (7)

•Web Resource (9)

Error Types

•Epidemiology of Errors and Adverse Events (101)

•Active Errors (117)

•Latent Errors (51)

•Near Miss (13)

Approach to Improving Safety
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Communication between Providers

•Read Back Protocols (84)

•Structured Hand-offs (43)

•SBAR (12)

•Medication Reconciliation (46)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (507)

•Health Care Executives and Administrators (513)

•Non-Health Care Professionals (229)

•Patients (46)

Setting of Care

•Hospitals (493)

•Psychiatric Facilities (2)

•Residential Facilities (15)

•Ambulatory Care (51)

•Outpatient Surgery (13)

•Patient Transport (6)

1 - 20 of 656

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ORGANIZATIONAL POLICY/GUIDELINES classic

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

The Joint Commission.

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.

COMMENTARY

Time out: an analysis.

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

NEWSPAPER/MAGAZINE ARTICLE

Hospital tells of surgery on wrong side.

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

COMMENTARY

Surgical site verification: A through Z.

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

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

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.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

STUDY

Surgical team behaviors and patient outcomes.

Mazzocco K, Petitti DB, Fong KT, et al. Am J Surg. 2009;197:678-685.

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

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

Tomorrow's operating room to harness Net, RFID.

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

NEWSPAPER/MAGAZINE ARTICLE

The wrong foot, and other tales of surgical error.

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

ORGANIZATIONAL POLICY/GUIDELINES

Statement on the prevention of retained foreign bodies after surgery.

Bulletin of the American College of Surgeons; October 2005.

STUDY

A surgical safety checklist to reduce morbidity and mortality in a global population.

Haynes AB, Weiser TG, Berry WR, et al; for the Safe Surgery Saves Lives Study Group. N Engl J Med. 2009;360:491-499.

BOOK/REPORT

Medmarx Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005.

Rockville, MD: United States Pharmacopeia; 2007.

COMMENTARY

Developing a medication patient safety program — infrastructure and strategy.

Mark SM, Weber RJ. Hosp Pharm. 2007;42:149-156.

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