AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (47)

•Diagnostic Errors (103)

•Identification Errors (92)

•Discontinuities, Gaps, and Hand-Off Problems (141)

•Fatigue and Sleep Deprivation (73)

•Medication Safety (292)

•Medical Complications (85)

•Nonsurgical Procedural Complications (26)

•Surgical Complications (506)

•Transfusion Complications (4)

•Psychological and Social Complications (71)

Origin/Sponsor
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United States of America

•United States Federal Government (42)

•State Governments and Agencies (7)

Resource Types

•Audiovisual (17)

•Award (1)

•Book/Report (33)

•Clinical Guideline (6)

•Journal Article (1011)

•Legislation/Regulation (24)

•Meeting/Conference (3)

•Newsletter/Journal (5)

•Newspaper/Magazine Article (200)

•Press Release/Announcement (3)

•Special or Theme Issue (13)

•Tools/Toolkit (24)

•Web Resource (27)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (279)

•Active Errors (226)

•Latent Errors (64)

•Near Miss (21)

Approach to Improving Safety

•Quality Improvement Strategies (294)

•Legal and Policy Approaches (130)

•Error Reporting and Analysis (382)

•Communication Improvement (347)

•Human Factors Engineering (172)

•Teamwork (134)

•Specialization of Care (56)

•Logistical Approaches (128)

•Culture of Safety (141)

•Technologic Approaches (196)

•Education and Training (305)

Clinical Areas

•Allied Health Services (1)

Target Audience

•Health Care Providers (1194)

•Health Care Executives and Administrators (845)

•Non-Health Care Professionals (413)

•Patients (146)

Setting of Care

•Hospitals (848)

•Psychiatric Facilities (1)

•Residential Facilities (6)

•Ambulatory Care (90)

•Outpatient Surgery (36)

•Patient Transport (4)

1 - 20 of 1368

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COMMENTARY

Surgical count practice variability and the potential for retained surgical items.

Edel EM. AORN J. 2012;95:228-238.

REVIEW

Preventable errors in the operating room: retained foreign bodies after surgery--part I.

Gibbs VC, Coakley FD, Reines HD. Curr Probl Surg. 2007;44:281-337.

STUDY

Retained foreign bodies after surgery.

Lincourt AE, Harrell A, Cristiano J, Sechrist C, Kercher K, Heniford BT. J Surg Res. 2007;138:170-174.

NEWSPAPER/MAGAZINE ARTICLE

Sponges, surgical instruments miscounted in 13% of surgeries.

O'Reilly KB. American Medical News. September 22, 2008;51:14.

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.

NEWSPAPER/MAGAZINE ARTICLE

Wrong-site surgery.

Butcher L. Hosp Health Netw. November 2011.

NEWSPAPER/MAGAZINE ARTICLE

'Wrong site' surgeries on the rise.

Davis R. USA Today. April 17, 2006.

STUDY

Risk factors for retained instruments and sponges after surgery.

Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. N Engl J Med. 2003;348:229-235.

STUDY

Effectiveness of a radiofrequency detection system as an adjunct to manual counting protocols for tracking surgical sponges: a prospective trial of 2,285 patients.

Rupp CC, Kagarise MJ, Nelson SM, et al. J Am Coll Surg. 2012;215:524-533.

STUDY

Operating room briefings and wrong-site surgery.

Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.

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.

COMMENTARY

Surgical site verification: A through Z.

Dunn D. J Perianesth Nurs. 2006;21:317-328.

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.

STUDY

Retained surgical items: a problem yet to be solved.

Stawicki SP, Moffatt-Bruce SD, Ahmed HM, et al. J Am Coll Surg. 2013;216:15-22.

STUDY

Getting surgery right.

Clarke JR, Johnston J, Finley ED. Ann Surg. 2007;246:395-405.

COMMENTARY

Surgical complications: disclosing adverse events and medical errors.

Wang AS, Eisen DB. J Am Acad Dermatol. 2013;68:144-146.

ORGANIZATIONAL POLICY/GUIDELINES classic

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery.

The Joint Commission.

AUDIOVISUAL

Using the Targeted Solutions Tool for wrong site surgery: is your organization at risk?

Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; February 13, 2012.

STUDY

Risk factors associated with incorrect surgical counts.

Rowlands A. AORN J. 2012;96:272-284.

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.

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