AHRQ Patient Safety Network

The Collection > United States of America

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Safety Target

•Device-related Complications (169)

•Diagnostic Errors (183)

•Identification Errors (146)

•Discontinuities, Gaps, and Hand-Off Problems (410)

•Fatigue and Sleep Deprivation (97)

•Medication Safety (1075)

•Medical Complications (438)

•Nonsurgical Procedural Complications (96)

•Surgical Complications (585)

•Transfusion Complications (19)

•Psychological and Social Complications (139)

Origin/Sponsor
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United States of America

•United States Federal Government (191)

•State Governments and Agencies (34)

Resource Types

•Clinical Guideline (9)

•Journal Article (2645)

•Legislation/Regulation (58)

•Meeting/Conference (30)

•Newsletter/Journal (12)

•Newspaper/Magazine Article (440)

•Press Release/Announcement (30)

•Special or Theme Issue (52)

•Tools/Toolkit (59)

•Web Resource (110)

•Grant (7)

Error Types

•Epidemiology of Errors and Adverse Events (1038)

•Active Errors (639)

•Latent Errors (219)

•Near Miss (74)

Approach to Improving Safety

•Quality Improvement Strategies (863)

•Legal and Policy Approaches (376)

•Error Reporting and Analysis (1090)

•Communication Improvement (897)

•Human Factors Engineering (490)

•Teamwork (305)

•Specialization of Care (233)

•Logistical Approaches (283)

•Culture of Safety (459)

•Technologic Approaches (627)

•Education and Training (723)

Clinical Areas

•Allied Health Services (9)

Target Audience

•Health Care Providers (2882)

•Health Care Executives and Administrators (2885)

•Non-Health Care Professionals (1321)

•Patients (381)

Setting of Care

•Hospitals (2293)

•Psychiatric Facilities (11)

•Residential Facilities (71)

•Ambulatory Care (358)

•Outpatient Surgery (55)

•Patient Transport (26)

1 - 20 of 3748

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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.

STUDY

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

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.

REVIEW

Avoiding wrong site surgery: a systematic review.

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

STUDY

Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study.

Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals collaborate to prevent wrong-site surgery.

Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.

STUDY

Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after 1,946,831 operations in children.

Camp M, Chang DC, Zhang Y, Chrouser K, Colombani PM, Abdullah F. Arch Surg. 2010;145:1085-1090.

REVIEW

Improving safety in the operating room: a systematic literature review of retained surgical sponges.

Wan W, Le T, Riskin L, Macario A. Curr Opin Anaesthesiol. 2009;22:207-214.

STUDY

Incorrect surgical procedures within and outside of the operating room.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.

STUDY

Wrong-site sinus surgery in otolaryngology.

Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.

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.

STUDY

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.

STUDY

Wrong site surgery near misses and actual occurrences.

Blanco M, Clarke JR, Martindell D. AORN J. 2009;90:215-222.

STUDY

Gossypiboma: tales of lost sponges and lessons learned.

McIntyre LK, Jurkovich GJ, Gunn MLD, Maier RV. Arch Surg. 2010;145:770-775.

STUDY

Surgical never events in the United States.

Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgery. 2013;153:465-472.

STUDY

Eight-year experience with a neurosurgical checklist.

Lyons MK. Am J Med Qual. 2010;25:285-288.

STUDY

Outcome of 6 years of protocol use for preventing wrong site office surgery.

Starling J 3rd, Coldiron BM. J Am Acad Dermatol. 2011;65:807-810.

STUDY

Medical errors in orthopaedics. Results of an AAOS member survey.

Wong DA, Herndon JH, Canale ST, et al. J Bone Joint Surg Am. 2009;91:547-557.

STUDY

Priority patient safety issues identified by perioperative nurses.

Steelman VM, Graling PR, Perkhounkova Y. AORN J. 2013;97:402-418.

NEWSPAPER/MAGAZINE ARTICLE

Preventing wrong-site surgery in Minnesota: a 5-year journey.

Rydrych D, Apold J, Harder K. Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34.

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