AHRQ Patient Safety Network

The Collection > United States of America

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Safety Target

•Device-related Complications (84)

•Diagnostic Errors (161)

•Identification Errors (107)

•Discontinuities, Gaps, and Hand-Off Problems (274)

•Fatigue and Sleep Deprivation (88)

•Medication Safety (534)

•Medical Complications (212)

•Nonsurgical Procedural Complications (49)

•Surgical Complications (594)

•Transfusion Complications (7)

•Psychological and Social Complications (155)

Origin/Sponsor
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United States of America

•United States Federal Government (85)

•State Governments and Agencies (16)

Resource Types

•Audiovisual (71)

•Award (9)

•Book/Report (120)

•Clinical Guideline (6)

•Journal Article (1493)

•Legislation/Regulation (33)

•Meeting/Conference (10)

•Newsletter/Journal (7)

•Newspaper/Magazine Article (510)

•Press Release/Announcement (8)

•Special or Theme Issue (29)

•Tools/Toolkit (44)

•Web Resource (70)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (383)

•Active Errors (373)

•Latent Errors (141)

•Near Miss (32)

Approach to Improving Safety

•Quality Improvement Strategies (534)

•Legal and Policy Approaches (325)

•Error Reporting and Analysis (638)

•Communication Improvement (777)

•Human Factors Engineering (283)

•Teamwork (265)

•Specialization of Care (125)

•Logistical Approaches (202)

•Culture of Safety (337)

•Technologic Approaches (329)

•Education and Training (551)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (1722)

•Health Care Executives and Administrators (1463)

•Non-Health Care Professionals (950)

•Patients (600)

Setting of Care

•Hospitals (1450)

•Psychiatric Facilities (4)

•Residential Facilities (24)

•Ambulatory Care (190)

•Outpatient Surgery (47)

•Patient Transport (12)

1 - 20 of 2413

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STUDY

Bridging the communication gap in the operating room with medical team training.

Awad SS, Fagan SP, Bellows C, et al. Am J Surg. 2005;190:770-774.

NEWSPAPER/MAGAZINE ARTICLE

In just a flash, simple surgery can turn deadly.

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

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

Communication in the perioperative setting.

Cvetic E. AORN J. 2011;94:261-270.

STUDY

Causes of near misses: perceptions of perioperative nurses.

Cohoon B. AORN J. 2011;93:551-565.

STUDY

Burnout and medical errors among American surgeons.

Shanafelt TD, Balch CM, Bechamps G, et al. Ann Surg. 2010;251:995-1000.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

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

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.

AUDIOVISUAL

Limiting medical mistakes.

Maminta J. News 8 WTNH. February 3, 2012.

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.

MULTI-USE WEBSITE

Strong for Surgery.

CERTAIN. Rockville, MD: Agency for Healthcare Research and Quality. SCOAP. Seattle, WA: Foundation for Health Care Quality.

STUDY

Action research, simulation, team communication, and bringing the tacit into voice. Society for Simulation in Healthcare.

Forsythe L. Simul Healthc. 2009;4:143-148.

NEWSPAPER/MAGAZINE ARTICLE

Tomorrow's operating room to harness Net, RFID.

Olsen S. CNET News.com; October 19, 2005.

COMMENTARY

Clinical care checklists: salvations or frustrations?

Jones JW, McCullough LB. J Vasc Surg. 2011;53:1429-1430.

COMMENTARY

A nurse-led approach to developing and implementing a collaborative count policy.

Norton EK, Micheli AJ, Gedney J, Felkerson TM. AORN J. 2012;95:222-227.

STUDY

Perceptions of patient safety culture among physicians and RNs in the perioperative area.

Scherer D, Fitzpatrick JJ. AORN J. 2008;87:163-175.

BOOK/REPORT

Medmarx Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005.

Rockville, MD: United States Pharmacopeia; 2007.

ORGANIZATIONAL POLICY/GUIDELINES

Statement on the prevention of retained foreign bodies after surgery.

Bulletin of the American College of Surgeons; October 2005.

STUDY

Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.

Steinberger DM, Douglas SV, Kirschbaum MS. Prog Transplant. 2009;19:208-215.

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