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 (33)

•Diagnostic Errors (20)

•Identification Errors (18)

•Discontinuities, Gaps, and Hand-Off Problems (49)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (150)

•Medical Complications (111)

•Nonsurgical Procedural Complications (23)

•Surgical Complications (108)

•Transfusion Complications (3)

•Psychological and Social Complications (43)

Origin/Sponsor

•Africa (1)

•Asia (7)

•Australia and New Zealand (23)

•Central and South America (2)

Resource Types

•Clinical Guideline (1)

•Journal Article (647)

•Legislation/Regulation (13)

•Meeting/Conference (17)

•Newspaper/Magazine Article (98)

•Press Release/Announcement (4)

•Special or Theme Issue (38)

•Tools/Toolkit (20)

•Web Resource (32)

•Grant (7)

Error Types

•Epidemiology of Errors and Adverse Events (94)

•Active Errors (67)

•Latent Errors (71)

•Near Miss (15)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (62)

•Red Rules (3)

•Institutional Patient Safety Plan (27)

•Just Culture (28)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (598)

•Health Care Executives and Administrators (877)

•Non-Health Care Professionals (474)

•Patients (60)

Setting of Care

•Hospitals (572)

•Psychiatric Facilities (4)

•Residential Facilities (26)

•Ambulatory Care (66)

•Outpatient Surgery (5)

•Patient Transport (8)

1 - 20 of 1015

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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.

SPECIAL OR THEME ISSUE

The English Patient Safety Programme.

J Health Serv Research Pol. 2010;15(suppl 1):S1-S91.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

NEWSPAPER/MAGAZINE ARTICLE

Get me out alive.

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

BOOK/REPORT classic

Patient Safety, 2nd edition.

Vincent C. West Sussex, UK: Wiley-Blackwell; 2010. ISBN: 9781405192217.

BOOK/REPORT

Safe Surgery Guide.

Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404073.

BOOK/REPORT

Advancing Patient Safety: A Decade of Evidence, Design, and Implementation.

Rockville, MD; Agency for Healthcare Research and Quality; November 2009. AHRQ Publication No. 09(10)-0084.

SPECIAL OR THEME ISSUE

Interprofessional Approaches to Patient Safety.

J Interprof Care. 2006;20:455-571.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

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

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.

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.

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.

SPECIAL OR THEME ISSUE

Patient Safety Papers 5.

Baker GR, ed. Healthc Q. 2010;13:1-136.

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.

STUDY

Error, stress, and teamwork in medicine and aviation: cross sectional surveys.

Sexton JB, Thomas EJ, Helmreich RL. BMJ. 2000;320:745-749.

COMMENTARY

Organizational Change in the Face of Highly Public Errors—II. The Duke Experience

Frush K. AHRQ WebM&M [serial online]. May 2005.

SPECIAL OR THEME ISSUE

Medical errors and safety systems.

Pearlman MD, ed. Clin Obstet Gynecol. 2010;53:471-585.

BOOK/REPORT

Safer Hospital Care: Strategies for Continuous Innovation.

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

NEWSPAPER/MAGAZINE ARTICLE

Trends influencing the cost of care and patient safety.

Clark R. Health Manage Tech. July 2006:18, 20-21.

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