AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (109)

•Diagnostic Errors (117)

•Identification Errors (152)

•Discontinuities, Gaps, and Hand-Off Problems (173)

•Fatigue and Sleep Deprivation (42)

•Medication Safety (528)

•Medical Complications (195)

•Nonsurgical Procedural Complications (51)

•Surgical Complications (542)

•Transfusion Complications (14)

•Psychological and Social Complications (95)

Origin/Sponsor
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United States of America

•United States Federal Government (85)

•State Governments and Agencies (20)

Resource Types

•Audiovisual (75)

•Award (11)

•Book/Report (109)

•Clinical Guideline (5)

•Journal Article (1131)

•Legislation/Regulation (29)

•Meeting/Conference (7)

•Newsletter/Journal (6)

•Newspaper/Magazine Article (485)

•Press Release/Announcement (15)

•Special or Theme Issue (22)

•Tools/Toolkit (52)

•Web Resource (80)

•Grant (5)

Error Types

•Epidemiology of Errors and Adverse Events (365)

•Active Errors (587)

•Latent Errors (139)

•Near Miss (51)

Approach to Improving Safety

•Quality Improvement Strategies (487)

•Legal and Policy Approaches (412)

•Error Reporting and Analysis (691)

•Communication Improvement (559)

•Human Factors Engineering (310)

•Teamwork (149)

•Specialization of Care (82)

•Logistical Approaches (137)

•Culture of Safety (238)

•Technologic Approaches (296)

•Education and Training (582)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (1347)

•Health Care Executives and Administrators (1298)

•Non-Health Care Professionals (676)

•Patients (606)

Setting of Care

•Hospitals (1235)

•Psychiatric Facilities (4)

•Residential Facilities (30)

•Ambulatory Care (159)

•Outpatient Surgery (46)

•Patient Transport (15)

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NEWSPAPER/MAGAZINE ARTICLE

Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.

Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.

NEWSPAPER/MAGAZINE ARTICLE

Medical mistakes unhappy reality.

Young A. The Atlanta Journal-Constitution. May 3, 2009:B1.

NEWSPAPER/MAGAZINE ARTICLE

'Wrong-site' surgical mistakes are rare, preventable.

Stein L. St. Petersburg Times. June 21, 2010.

NEWSPAPER/MAGAZINE ARTICLE

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

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

NEWSPAPER/MAGAZINE ARTICLE

The pain of wrong site surgery.

Boodman SG. Washington Post. June 21, 2011:E1.

NEWSPAPER/MAGAZINE ARTICLE

Most surgery in wrong spot done on spine: 11 such cases found in state since 2006.

Smith S. Boston Globe. July 30, 2008;Metro section:1A.

COMMENTARY

Time out: an analysis.

Dillon KA. AORN J. 2008;88:437-442.

MULTI-USE WEBSITE

Minnesota Time Out Campaign.

Minnesota Safe Surgery Coalition. June 15, 2011.

COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

NEWSPAPER/MAGAZINE ARTICLE

Clinic sued over towel left in patient.

McCarty JF. Plain Dealer. January 16, 2007:A1.

NEWSPAPER/MAGAZINE ARTICLE

Medical culture about errors may be changing.

Gulliver D. Herald Tribune. September 3, 2007.

NEWSPAPER/MAGAZINE ARTICLE

Doctor removes ovaries from wrong patient.

Bramson K, Mooney T. Providence Journal. August 18, 2006.

STUDY

Process changes to increase compliance with the Universal Protocol for bedside procedures.

Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.

NEWSPAPER/MAGAZINE ARTICLE

In just a flash, simple surgery can turn deadly.

Landro L. Wall Street Journal. February 18, 2009:D1.

NEWSPAPER/MAGAZINE ARTICLE

How to avoid falling victim to a hospital mistake.

Cohen E. Empowered Patient. CNN.com. November 13, 2009.

REVIEW

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.

COMMENTARY

The 5th anniversary of the "Universal Protocol": pitfalls and pearls revisited.

Stahel PF, Mehler PS, Clarke TJ, Varnell J. Patient Saf Surg. 2009;3:14.

COMMENTARY classic

Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand.

Ring DC, Herndon JH, Meyer GS. N Engl J Med. 2010;363:1950-1957.

NEWSPAPER/MAGAZINE ARTICLE

Preventing surgical errors.

Frenzel JC, Kelly T. HHN Magazine Online. January 6, 2009.

REVIEW

Avoiding wrong site surgery: a systematic review.

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

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