AHRQ Patient Safety Network

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•Device-related Complications (11)

•Diagnostic Errors (7)

•Identification Errors (17)

•Discontinuities, Gaps, and Hand-Off Problems (54)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (59)

•Medical Complications (57)

•Nonsurgical Procedural Complications (13)

•Surgical Complications (132)

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•Journal Article (370)

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•Newspaper/Magazine Article (44)

•Special or Theme Issue (24)

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•Epidemiology of Errors and Adverse Events (43)

•Active Errors (43)

•Latent Errors (24)

•Near Miss (5)

Approach to Improving Safety
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Teamwork

•Teamwork Training (100)

Clinical Areas

•Allied Health Services (1)

•Medicine (355)

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Target Audience

•Health Care Providers (348)

•Health Care Executives and Administrators (411)

•Non-Health Care Professionals (233)

•Patients (14)

Setting of Care

•Hospitals (356)

•Psychiatric Facilities (1)

•Residential Facilities (5)

•Ambulatory Care (21)

•Outpatient Surgery (5)

•Patient Transport (5)

1 - 20 of 490

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STUDY

Causes of near misses: perceptions of perioperative nurses.

Cohoon B. AORN J. 2011;93:551-565.

STUDY

Interruptions and miscommunications in surgery: an observational study.

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

ORGANIZATIONAL POLICY/GUIDELINES

AORN guidance statement: creating a patient safety culture.

AORN J. 2006;83:936-942.

COMMENTARY

"Managing up" can improve teamwork in the OR.

Smith SL. AORN J. 2010;91:576-582.

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.

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.

STUDY

Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR.

Lingard L, Espin S, Rubin B, et al. Qual Saf Health Care. 2005;14:340-346.

NEWSPAPER/MAGAZINE ARTICLE

The pain of wrong site surgery.

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

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.

MEETING/CONFERENCE PROCEEDINGS

Safety in the NICU: preventing medical errors.

Stokowski LA. Highlights of the National Association of Neonatal Nurses 22nd Annual Conference [Medscape.com]. March 8, 2007.

STUDY

Nurses' perceptions and experiences of communication in the operating theatre: a focus group interview.

Nestel D, Kidd JM. BMC Nurs. 2006 Feb 8;5:1.

STUDY

Governing the surgical count through communication interactions: implications for patient safety.

Riley R, Manias E, Polglase A. Qual Saf Health Care. 2006;15:369-374.

REVIEW

Enhancing communication in surgery through team training interventions: a systematic literature review.

Gillespie BM, Chaboyer W, Murray P. AORN J. 2010;92:642-657.

COMMENTARY

Improving patient safety and communication through care rounds in a pediatric oncology outpatient clinic.

Blough CA, Walrath JM. J Nurs Care Qual. 2007;22:159-163.

STUDY

Wrong site surgery near misses and actual occurrences.

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

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.

STUDY

Relationship between systems-level factors and hand hygiene adherence.

Dunn-Navarra AM, Cohen B, Stone PW, Pogorzelska M, Jordan S, Larson E. J Nurs Care Qual. 2011;26:30-38.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals collaborate to prevent wrong-site surgery.

Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.

STUDY

Impact of preoperative briefings on operating room delays.

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

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