AHRQ Patient Safety Network

PATIENT SAFETY PRIMERS
Safety Culture

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Safety Culture: High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work... Read Full Glossary Entry >

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Safety Target

•Device-related Complications (31)

•Diagnostic Errors (19)

•Identification Errors (17)

•Discontinuities, Gaps, and Hand-Off Problems (46)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (131)

•Medical Complications (105)

•Nonsurgical Procedural Complications (22)

•Surgical Complications (107)

•Transfusion Complications (3)

•Psychological and Social Complications (41)

Origin/Sponsor

•Africa (1)

•Asia (7)

•Australia and New Zealand (20)

•Central and South America (2)

Resource Types

•Clinical Guideline (1)

•Journal Article (607)

•Legislation/Regulation (14)

•Meeting/Conference (18)

•Newspaper/Magazine Article (97)

•Press Release/Announcement (4)

•Special or Theme Issue (37)

•Tools/Toolkit (18)

•Web Resource (28)

•Grant (6)

Error Types

•Epidemiology of Errors and Adverse Events (87)

•Active Errors (65)

•Latent Errors (69)

•Near Miss (15)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (52)

•Red Rules (3)

•Institutional Patient Safety Plan (22)

•Just Culture (24)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (578)

•Health Care Executives and Administrators (834)

•Non-Health Care Professionals (441)

•Patients (60)

Setting of Care

•Hospitals (545)

•Psychiatric Facilities (5)

•Residential Facilities (26)

•Ambulatory Care (60)

•Outpatient Surgery (5)

•Patient Transport (7)

1 - 20 of 963

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SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.

NEWSPAPER/MAGAZINE ARTICLE

A hospital races to learn lessons of Ferrari pit stop.

Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].

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.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

COMMENTARY

Surgical team training: promoting high reliability with nontechnical skills.

Paige JT. Surg Clin North Am. 2010;90:569-581.

BOOK/REPORT classic

Patient Safety in Emergency Medicine.

Croskerry P, Cosby KS, Schenkel SM, Wears RL, eds. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. ISBN: 9780781777278.

NEWSPAPER/MAGAZINE ARTICLE

Saving lives: hospitals have signed on to a six-part plan to avoid a multitude of unnecessary deaths.

Comarow A. US News & World Report. July 18, 2005;139:74,76,79.

NEWSPAPER/MAGAZINE ARTICLE

Bringing surgeons down to earth.

Landro L. Wall Street Journal (Eastern edition). November 16, 2005:D1.

STUDY

Improving operating room safety.

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

NEWSPAPER/MAGAZINE ARTICLE

Get me out alive.

Feldman R. The Washington Post. May 2, 2006:HE01.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

STUDY

How does patient safety culture in the operating room and post-anesthesia care unit compare to the rest of the hospital?

Kaafarani HM, Itani KM, Rosen AK, Zhao S, Hartmann CW, Gaba DM. Am J Surg. 2009;198:70-75.

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.

STUDY

Safety culture and complications after bariatric surgery.

Birkmeyer NJ, Finks JF, Greenberg CK, et al. Ann Surg. 2013;257:260-265.

COMMENTARY

Quality and safety initiatives in the future practice of surgery: meeting patient demands for enhanced professionalism.

Russell TR. Surg Today. 2009;39:739-745.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion No. 447: patient safety in obstetrics and gynecology.

ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2009;114:1424-1427.

BOOK/REPORT

Safer Hospital Care: Strategies for Continuous Innovation.

Raheja D. New York, NY: Productivity Press; 2011. ISBN: 9781439821022.

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.

AWARD RECIPIENT

An interview with Lucian Leape.

Leape LL. Jt Comm J Qual Saf. 2004;30:653-658.

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