AHRQ Patient Safety Network

The Collection > United States of America

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Safety Target

•Device-related Complications (99)

•Diagnostic Errors (119)

•Identification Errors (114)

•Discontinuities, Gaps, and Hand-Off Problems (195)

•Fatigue and Sleep Deprivation (47)

•Medication Safety (576)

•Medical Complications (224)

•Nonsurgical Procedural Complications (38)

•Surgical Complications (582)

•Transfusion Complications (11)

•Psychological and Social Complications (61)

Origin/Sponsor
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United States of America

•United States Federal Government (57)

•State Governments and Agencies (11)

Resource Types

•Audiovisual (26)

•Award (4)

•Book/Report (50)

•Clinical Guideline (5)

•Journal Article (1373)

•Legislation/Regulation (21)

•Meeting/Conference (4)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (234)

•Press Release/Announcement (3)

•Special or Theme Issue (15)

•Tools/Toolkit (15)

•Web Resource (25)

Error Types

•Epidemiology of Errors and Adverse Events (985)

•Active Errors (538)

•Latent Errors (108)

•Near Miss (58)

Approach to Improving Safety

•Quality Improvement Strategies (349)

•Legal and Policy Approaches (163)

•Error Reporting and Analysis (608)

•Communication Improvement (404)

•Human Factors Engineering (268)

•Teamwork (130)

•Specialization of Care (92)

•Logistical Approaches (141)

•Culture of Safety (165)

•Technologic Approaches (289)

•Education and Training (310)

Clinical Areas

•Allied Health Services (5)

Target Audience

•Health Care Providers (1256)

•Health Care Executives and Administrators (1253)

•Non-Health Care Professionals (513)

•Patients (191)

Setting of Care

•Hospitals (1290)

•Psychiatric Facilities (4)

•Residential Facilities (33)

•Ambulatory Care (182)

•Outpatient Surgery (50)

•Patient Transport (20)

1 - 20 of 1776

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REVIEW

Minimizing surgical error by incorporating objective assessment into surgical education.

Champion HR, Meglan DA, Shair EK. J Am Coll Surg. 2008;207:284-291.

BOOK/REPORT

Annual Benchmarking Report: Malpractice Risks in Surgery.

Cambridge, MA: CRICO/RMF Strategies; 2010.

COMMENTARY

The nature of surgical error: a cautionary tale and a call to reason.

Satava RM. Surg Endosc. 2005;19:1014-1016.

STUDY

Surgical case listing accuracy: failure analysis at a high-volume academic medical center.

Cima RR, Hale C, Kollengode A, Rogers JC, Cassivi SD, Deschamps C. Arch Surg. 2010;145:641-646.

NEWSPAPER/MAGAZINE ARTICLE

Entire UPMC transplant team missed hepatitis alert.

Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.

REVIEW

Missed injuries in trauma patients: a literature review.

Pfeifer R, Pape HC. Patient Saf Surg. 2008;2:20.

STUDY

Applicability of Healthcare Failure Mode and Effects Analysis to healthcare epidemiology: evaluation of the sterilization and use of surgical instruments.

Linkin DR, Sausman C, Santos L, et al. Clin Infect Dis. 2005;41:1014-1019.

STUDY

Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital.

Vermaire D, Caruso MC, Lesko A, et al. BMJ Qual Saf. 2011;20:895-902.

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

Burnout and medical errors among American surgeons.

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

STUDY

Benchmarking surgical incident reports using a database and a triage system to reduce adverse outcomes.

Antonacci AC, Lam S, Lavarias V, Homel P, Eavey RD. Arch Surg. 2008;143:1192-1197.

STUDY

Incidence and characteristics of potential and actual retained foreign object events in surgical patients.

Cima RR, Kollengode A, Garnatz J, et al. J Am Coll Surg. 2008;207:80-87.

STUDY

Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program.

Kiran RP, Ahmed Ali U, Coffey JC, Vogel JD, Pokala N, Fazio VW. Ann Surg. 2012;256:469-475.

REVIEW

Avoiding wrong site surgery: a systematic review.

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

NEWSPAPER/MAGAZINE ARTICLE

A towel with a safety message.

Lerner M. Minneapolis Star Tribune. January 25, 2009:B1.

STUDY

Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients.

Regenbogen SE, Greenberg CC, Studdert DM, Lipsitz SR, Zinner MJ, Gawande AA. Ann Surg. 2007;246:705-711.

STUDY

Classification of adverse events occurring in a surgical intensive care unit.

Frankel H, Sperry J, Kaplan L, Foley A, Rabinovici R. Am J Surg. 2007;194:328-332.

STUDY

Communication failure in the operating room.

Halverson AL, Casey JT, Andersson J, et al. Surgery. 2011;49:305-310.

NEWSPAPER/MAGAZINE ARTICLE

Revealing their medical errors: why three doctors went public.

O'Reilly KB. American Medical News. August 15, 2011.

STUDY

Safety on an inpatient pediatric otolaryngology service: many small errors, few adverse events.

Shah RK, Lander L, Forbes P, Jenkins K, Healy GB, Roberson DW. Laryngoscope. 2009;119:871-879.

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