AHRQ Patient Safety Network

The Collection > Logistical Approaches

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Safety Target

•Device-related Complications (6)

•Diagnostic Errors (16)

•Identification Errors (23)

•Discontinuities, Gaps, and Hand-Off Problems (92)

•Fatigue and Sleep Deprivation (91)

•Medication Safety (100)

•Medical Complications (44)

•Nonsurgical Procedural Complications (5)

•Surgical Complications (50)

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•Journal Article (312)

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•Special or Theme Issue (8)

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Error Types

•Epidemiology of Errors and Adverse Events (87)

•Active Errors (37)

•Latent Errors (28)

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Approach to Improving Safety
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Logistical Approaches

•Laboratory Result Tracking Improvement (58)

•Nurse Staffing Ratios (29)

•Scheduling Changes (23)

•Duty Hour Limitation (110)

Clinical Areas

•Medicine (260)

•Nursing (68)

•Pharmacy (36)

Target Audience

•Health Care Providers (289)

•Health Care Executives and Administrators (305)

•Non-Health Care Professionals (147)

•Patients (21)

Setting of Care

•Hospitals (281)

•Residential Facilities (3)

•Ambulatory Care (28)

•Outpatient Surgery (3)

•Patient Transport (3)

1 - 20 of 393

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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.

STUDY

Effect of short-term pretrial practice on surgical proficiency in simulated environments: a randomized trial of the "preoperative warm-up" effect.

Kahol K, Satava RM, Ferrara J, Smith ML. J Am Coll Surg. 2009;208:255-268.

STUDY

Correlation of workload with disagreement and amendment rates in surgical pathology and nongynecologic cytology.

Renshaw AA, Gould EW. Am J Clin Pathol. 2006;125:820-822.

STUDY

What is the safety of nonemergent operative procedures performed at night?

Turrentine FE, Wang H, Young JS, Calland JF. J Trauma. 2010;69:313-319.

REVIEW

Patient safety and error reduction in surgical pathology.

Nakhleh RE. Arch Pathol Lab Med. 2008;132:181-185.

STUDY

Promoting patient safety through prospective risk identification: example from peri-operative care.

Smith A, Boult M, Woods I, Johnson S. Qual Saf Health Care. 2010;19:69-73.

REVIEW

Avoiding wrong site surgery: a systematic review.

DeVine J, Chutkan N, Norvell DC, Dettori JR. Spine. 2010;35(suppl 9):S28-S36.

STUDY

The 80-hour work guidelines and resident survey perceptions of quality.

Biller CK, Antonacci AC, Pelletier S, et al. J Surg Res. 2006;135:275-281.

NEWSPAPER/MAGAZINE ARTICLE

How hospital design saves lives.

Blum A. Business Week. August 15, 2006.

NEWSPAPER/MAGAZINE ARTICLE

"Near injury" alters procedures at Virginia Mason.

Ostrom CM. The Seattle Times. May 21, 2005.

COMMENTARY

Sleep deprivation, elective surgical procedures, and informed consent.

Nurok M, Czeisler CA, Lehmann LS. N Engl J Med. 2010;363:2577-2579.

COMMENTARY

Work system design for patient safety: the SEIPS model.

Carayon P, Schoofs Hundt A, Karsh BT, et al. BMJ Qual Saf. 2006;15(supp 1):i50-i58.

STUDY

Association between Leapfrog safe practices score and hospital mortality in major surgery.

Qian F, Lustik SJ, Diachun CA, Wissler RN, Zollo RA, Glance LG. Med Care. 2011;49:1082-1088.

STUDY

Implementation of resident work hour restrictions is associated with a reduction in mortality and provider-related complications on the surgical service: a concurrent analysis of 14,610 patients.

Privette AR, Shackford SR, Osler T, Ratliff J, Sartorelli K, Hebert JC. Ann Surg. 2009;250:316-321.

NEWSPAPER/MAGAZINE ARTICLE

Lost surgical specimens, lost opportunities.

PA-PSRS Patient Saf Advis. September 2005;2:1-5.

COMMENTARY

Attending work hour restrictions: is it time?

Hyman NH. Arch Surg. 2009;144:7-8.

STUDY

Surgical training, duty-hour restrictions, and implications for meeting the Accreditation Council for Graduate Medical Education core competencies: views of surgical interns compared with program directors.

Antiel RM, Van Arendonk KJ, Reed DA, et al. Arch Surg. 2012;147:536-541.

STUDY

Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors.

Wagar EA, Tamashiro L, Yasin B, Hilborne L, Bruckner DA. Arch Pathol Lab Med. 2006;130:1662-1668.

COMMENTARY

Resident duty hours in surgery for ensuring patient safety, providing optimum resident education and training, and promoting resident well-being: a response from the American College of Surgeons to the Report of the Institute of Medicine, "Resident Duty Hours: Enhancing Sleep, Supervision, and Safety."

Britt LD, Sachdeva AK, Healy GB, Whalen TV, Blair PG; Members of the ACS Task Force on Resident Duty Hours. Surgery. 2009;146:398-409.

STUDY

Medical errors arising from outsourcing laboratory and radiology services.

Chasin BS, Elliott SP, Klotz SA. Am J Med. 2007;120:819.e9-11.

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