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 (25)

•Diagnostic Errors (5)

•Identification Errors (15)

•Discontinuities, Gaps, and Hand-Off Problems (21)

•Fatigue and Sleep Deprivation (5)

•Medication Safety (93)

•Medical Complications (70)

•Nonsurgical Procedural Complications (16)

•Surgical Complications (99)

•Transfusion Complications (1)

•Psychological and Social Complications (26)

Origin/Sponsor

•Asia (4)

•Australia and New Zealand (7)

Resource Types

•Clinical Guideline (1)

•Journal Article (453)

•Legislation/Regulation (10)

•Meeting/Conference (8)

•Newspaper/Magazine Article (79)

•Press Release/Announcement (2)

•Special or Theme Issue (20)

•Tools/Toolkit (9)

•Web Resource (16)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (62)

•Active Errors (38)

•Latent Errors (43)

•Near Miss (9)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (6)

•Red Rules (2)

•Institutional Patient Safety Plan (5)

•Just Culture (6)

Clinical Areas

•Allied Health Services (3)

•Complementary and Alternative Medicine (1)

Target Audience

•Health Care Providers (414)

•Health Care Executives and Administrators (581)

•Non-Health Care Professionals (294)

•Patients (61)

Setting of Care

•Hospitals (415)

•Psychiatric Facilities (2)

•Residential Facilities (17)

•Ambulatory Care (34)

•Outpatient Surgery (5)

•Patient Transport (5)

1 - 20 of 687

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NEWSPAPER/MAGAZINE ARTICLE

Wrong body part, wrong patient surgeries continue despite new procedures.

Rojas-Burke J. The Oregonian. May 25, 2011.

STUDY

Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable?

Seiden SC, Barach P. Arch Surg. 2006;141:931-939.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

MULTI-USE WEBSITE

Patient Safety First.

AORN, Inc., 2170 South Parker Rd, Suite 300, Denver, CO 80231-5711.

COMMENTARY

Mark My Limb.

O'Leary DS, Jacott WE. AHRQ WebM&M [serial online]. December 2004.

NEWSPAPER/MAGAZINE ARTICLE

Wrong-site surgery.

Butcher L. Hosp Health Netw. November 2011.

NEWSPAPER/MAGAZINE ARTICLE

Global goal: reduce medical errors.

Szabo L. USA Today. August 23, 2005.

BOOK/REPORT

National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare.

National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.

STUDY

The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery.

James MA, Seiler JG 3rd, Harrast JJ, Emery SE, Hurwitz S. J Bone Joint Surg Am. 2012;94:e2(1-12).

NEWSPAPER/MAGAZINE ARTICLE

5 sure-fire methods: complying with NPSG.03.04.01.

Joint Commission: The Source. January 2012;10:5-6.

STUDY

The relationship of the emotional climate of work and threat to patient outcome in a high-volume thoracic surgery operating room team.

Nurok M, Evans LA, Lipsitz S, Satwicz P, Kelly A, Frankel A. BMJ Qual Saf. 2011;20:237-242.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

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

STUDY

Communication practices on 4 Harvard surgical services: a surgical safety collaborative.

ElBardissi AW, Regenbogen SE, Greenberg CC, et al. Ann Surg. 2009;250:861-865.

COMMENTARY

"Managing up" can improve teamwork in the OR.

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

STUDY

Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.

Espin S, Levinson W, Regehr G, Baker GR, Lingard L. Surgery. 2006;139:6-14.

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.

AUDIOVISUAL

Good News: How Hospitals Heal Themselves [documentary].

Washington, DC: CCM, Inc.; 2006. Crawford-Mason C (producer), Dobyns L (reporter); Management Wisdom Video Series.

COMMENTARY

Retained surgical items and minimally invasive surgery.

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

STUDY

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

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

STUDY

Continuous monitoring of adverse events: influence on the quality of care and the incidence of errors in general surgery.

Rebasa P, Mora L, Luna A, Montmany S, Vallverdú H, Navarro S. World J Surg. 2009;33:191-198.

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