AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (10)

•Diagnostic Errors (10)

•Identification Errors (17)

•Discontinuities, Gaps, and Hand-Off Problems (55)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (64)

•Medical Complications (60)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (135)

•Psychological and Social Complications (41)

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•Special or Theme Issue (29)

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•Epidemiology of Errors and Adverse Events (49)

•Active Errors (43)

•Latent Errors (25)

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Approach to Improving Safety
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Teamwork

•Teamwork Training (121)

Clinical Areas

•Allied Health Services (3)

•Medicine (388)

•Nursing (76)

•Pharmacy (13)

Target Audience

•Health Care Providers (398)

•Health Care Executives and Administrators (444)

•Non-Health Care Professionals (281)

•Patients (18)

Setting of Care

•Hospitals (380)

•Psychiatric Facilities (1)

•Residential Facilities (5)

•Ambulatory Care (27)

•Outpatient Surgery (5)

•Patient Transport (6)

1 - 20 of 544

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STUDY

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

REVIEW

Determining the state of knowledge for implementing the Universal Protocol recommendations: an integrative review of the literature.

Conrardy JA, Brenek B, Myers S. AORN J. 2010;92:194-207.

ORGANIZATIONAL POLICY/GUIDELINES

Safe Site Invasive Procedure—Non-Operating Room.

Bloomington, MN: Institute for Clinical Systems Improvement; 2010.

STUDY

Wrong site surgery near misses and actual occurrences.

Blanco M, Clarke JR, Martindell D. AORN J. 2009;90:215-222.

STUDY

Incorrect surgical procedures within and outside of the operating room.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

NEWSPAPER/MAGAZINE ARTICLE

The pain of wrong site surgery.

Boodman SG. Washington Post. June 21, 2011:E1.

COMMENTARY

Retained surgical items and minimally invasive surgery.

Gibbs VC. World J Surg. 2011;35:1532-1539.

STUDY

Operating room briefings and wrong-site surgery.

Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.

COMMENTARY

Reducing surgical complications.

Griffin FA. Jt Comm J Qual Patient Saf. 2007;33:660-665.

STUDY

Identifying opportunities for quality improvement in surgical site infection prevention.

Gagliardi AR, Eskicioglu C, McKenzie M, Fenech D, Nathens A, McLeod R. Am J Infect Control. 2009;37:398-402.

COMMENTARY

Increasing patient safety and surgical team communication by using a count/time out board.

Edel EM. AORN J. 2010;92:420-424.

STUDY

Impact of preoperative briefings on operating room delays.

Nundy S, Mukherjee A, Sexton JB, et al. Arch Surg. 2008;143:1068-1072.

STUDY

Interruptions and miscommunications in surgery: an observational study.

Gillespie BM, Chaboyer W, Fairweather N. AORN J. 2012;95:576-590.

COMMENTARY

Inadvertent Castration.

Calland JF. AHRQ WebM&M [serial online]. January 2004.

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.

STUDY

Improved operating room teamwork via SAFETY prep: a rural community hospital's experience.

Paige JT, Aaron DL, Yang T, Howell DS, Chauvin SW. World J Surg. 2009;33:1181-1187.

STUDY

Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention.

Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. BMJ Qual Saf. 2011;20:102-107.

REVIEW

Can we make postoperative patient handovers safer? A systematic review of the literature.

Segall N, Bonifacio AS, Schroeder RA, et al; Durham VA Patient Safety Center of Inquiry. Anesth Analg. 2012;115:102-115.

STUDY

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

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