AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (5)

•Diagnostic Errors (6)

•Identification Errors (9)

•Discontinuities, Gaps, and Hand-Off Problems (25)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (57)

•Medical Complications (21)

•Nonsurgical Procedural Complications (8)

•Surgical Complications (90)

•Transfusion Complications (2)

•Psychological and Social Complications (16)

Origin/Sponsor
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United Kingdom

Resource Types

•Audiovisual (1)

•Book/Report (21)

•Clinical Guideline (1)

•Journal Article (238)

•Legislation/Regulation (2)

•Meeting/Conference (1)

•Newspaper/Magazine Article (13)

•Special or Theme Issue (13)

•Tools/Toolkit (2)

•Web Resource (6)

Error Types

•Epidemiology of Errors and Adverse Events (53)

•Active Errors (35)

•Latent Errors (12)

•Near Miss (5)

Approach to Improving Safety

•Quality Improvement Strategies (75)

•Legal and Policy Approaches (18)

•Error Reporting and Analysis (85)

•Communication Improvement (99)

•Human Factors Engineering (51)

•Teamwork (82)

•Specialization of Care (5)

•Logistical Approaches (14)

•Culture of Safety (42)

•Technologic Approaches (24)

•Education and Training (126)

Clinical Areas

•Allied Health Services (1)

•Medicine (215)

•Nursing (39)

•Pharmacy (11)

Target Audience

•Health Care Providers (216)

•Health Care Executives and Administrators (238)

•Non-Health Care Professionals (146)

•Patients (8)

Setting of Care

•Hospitals (182)

•Psychiatric Facilities (4)

•Residential Facilities (3)

•Ambulatory Care (12)

•Outpatient Surgery (2)

•Patient Transport (7)

1 - 20 of 298

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COMMENTARY

A common body of care: the ethics and politics of teamwork in the operating theater are inseparable.

Bleakley A. J Med Philos. 2006;31:305-322.

STUDY

Reliability of a revised NOTECHS scale for use in surgical teams.

Sevdalis N, Davis R, Koutantji M, et al. Am J Surg. 2008;196:184-190.

COMMENTARY

Defining the technical skills of teamwork in surgery.

Healey AN, Undre S, Vincent CA. Qual Saf Health Care. 2006;15:231-234.

STUDY

Observational assessment of surgical teamwork: a feasibility study.

Undre S, Healey AN, Darzi A, Vincent CA. World J Surg. 2006;30:1774-1783.

STUDY

Teamwork in the operating theatre: cohesion or confusion?

Undre S, Sevdalis N, Healey AN, Darzi A, Vincent CA. J Eval Clin Pract. 2006;12:182-189.

SPECIAL OR THEME ISSUE

Enhancing Surgical Systems.

Healey AN, Catchpole K, Yule S. Cogn Tech Work. 2008;10:249-333.

STUDY

Observational teamwork assessment for surgery: feasibility of clinical and nonclinical assessor calibration with short-term training.

Russ S, Hull L, Rout S, Vincent C, Darzi A, Sevdalis N. Ann Surg. 2012;255:804-809.

REVIEW

Do calculation errors by nurses cause medication errors in clinical practice? A literature review.

Wright K. Nurse Educ Today. 2010;30:85-97.

MULTI-USE WEBSITE

Patient Safety Toolkits & E-learning Packages.

National Patient Safety Agency.

STUDY

Attitudes to teamwork and safety in the operating theatre.

Flin R, Yule S, McKenzie L, Paterson-Brown S, Maran N. Surgeon. June 2006;4:145-151.

STUDY

The culture of a trauma team in relation to human factors.

Cole E, Crichton N. J Clin Nurs. 2006;15:1257-1266.

STUDY

A human factors analysis of technical and team skills among surgical trainees during procedural simulations in a simulated operating theatre.

Moorthy K, Munz Y, Adams S, Pandey V, Darzi A. Ann Surg. 2005;242:631-639.

REVIEW

Surgical fires, a clear and present danger.

Yardley IE, Donaldson LJ. Surgeon. 2010;8:87-92.

STUDY

Surgical crisis management skills training and assessment: a stimulation-based approach to enhancing operating room performance.

Moorthy K, Munz Y, Forrest D, et al. Ann Surg. 2006;244:139-147.

STUDY

Use of briefings and debriefings as a tool in improving team work, efficiency, and communication in the operating theatre.

Bethune R, Sasirekha G, Sahu A, Cawthorn S, Pullyblank A. Postgrad Med J. 2011;87:331-334.

STUDY

Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors' and nurses' views.

McDonald R, Waring J, Harrison S, Walshe K, Boaden R. Qual Saf Health Care. 2005;14:290-294.

STUDY

Creating an improvement culture for enhanced patient safety: service improvement learning in pre-registration education.

Christiansen A, Robson L, Griffith-Evans C. J Nurs Manag. 2010;18:782-788.

STUDY

Development of a rating system for surgeons' non-technical skills.

Yule S, Flin R, Paterson-Brown S, Maran N, Rowley D. Med Educ. 2006;40:1098-1104.

STUDY

Information needs in operating room teams: what is right, what is wrong, and what is needed?

Wong HW, Forrest D, Healey A, et al. Surg Endosc. 2011;25:1913-1920.

STUDY

The struggle to improve patient care in the face of professional boundaries.

Powell AE, Davies HT. Soc Sci Med. 2012;75:807-814.

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