AHRQ Patient Safety Network

The Collection > Health Care Executives and Administrators

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Safety Target

•Device-related Complications (140)

•Diagnostic Errors (128)

•Identification Errors (112)

•Discontinuities, Gaps, and Hand-Off Problems (324)

•Fatigue and Sleep Deprivation (112)

•Medication Safety (782)

•Medical Complications (311)

•Nonsurgical Procedural Complications (61)

•Surgical Complications (545)

•Transfusion Complications (16)

•Psychological and Social Complications (133)

Origin/Sponsor

•Africa (1)

•Asia (22)

•Australia and New Zealand (59)

•Central and South America (3)

•Europe (282)

•North America (2879)

Resource Types

•Clinical Guideline (3)

•Journal Article (2428)

•Legislation/Regulation (39)

•Meeting/Conference (29)

•Newsletter/Journal (7)

•Newspaper/Magazine Article (344)

•Press Release/Announcement (13)

•Special or Theme Issue (63)

•Tools/Toolkit (47)

•Web Resource (62)

•Grant (7)

Error Types

•Epidemiology of Errors and Adverse Events (603)

•Active Errors (529)

•Latent Errors (198)

•Near Miss (68)

Approach to Improving Safety

•Quality Improvement Strategies (885)

•Legal and Policy Approaches (387)

•Error Reporting and Analysis (912)

•Communication Improvement (760)

•Human Factors Engineering (488)

•Teamwork (378)

•Specialization of Care (200)

•Logistical Approaches (274)

•Culture of Safety (827)

•Technologic Approaches (514)

•Education and Training (683)

Clinical Areas

•Allied Health Services (11)

Target Audience
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Health Care Executives and Administrators

•Facility and Group Administrators (240)

•Nurse Managers (477)

•Risk Managers (381)

•Quality and Safety Professionals (1101)

Setting of Care

•Hospitals (2070)

•Psychiatric Facilities (11)

•Residential Facilities (59)

•Ambulatory Care (198)

•Outpatient Surgery (38)

•Patient Transport (20)

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COMMENTARY

Surgical site verification: A through Z.

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

STUDY

Error, stress, and teamwork in medicine and aviation: cross sectional surveys.

Sexton JB, Thomas EJ, Helmreich RL. BMJ. 2000;320:745-749.

ORGANIZATIONAL POLICY/GUIDELINES classic

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

The Joint Commission.

COMMENTARY

Creating a culture of safety by using checklists.

Huang L, Kim R, Berry W. AORN J. 2013;97:365-368.

NEWSPAPER/MAGAZINE ARTICLE

'Wrong site' surgeries on the rise.

Davis R. USA Today. April 17, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Bringing surgeons down to earth.

Landro L. Wall Street Journal (Eastern edition). November 16, 2005:D1.

NEWSPAPER/MAGAZINE ARTICLE

Doctor uses 'pre-flight' checklist.

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

STUDY

Incidence, patterns, and prevention of wrong-site surgery.

Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.

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.

STUDY

Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work.

Nemeth C, O’Connor M, Klock PA, Cook R. Org Stud. 2006;27:1011-1035.

STUDY

Thirty-day outcomes support implementation of a surgical safety checklist.

Bliss LA, Ross-Richardson CB, Sanzari LJ, et al. J Am Coll Surg. 2012;215:766-776.

COMMENTARY

DNR in the OR and Afterwards

Lo B. AHRQ WebM&M [serial online]. September 2006.

STUDY

The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases.

Wolf FA, Way LW, Stewart L. Ann Surg. 2010;252:477-485.

COMMENTARY

Implementing the World Health Organization surgical safety checklist: a model for future perioperative initiatives.

Styer KA, Ashley SW, Schmidt S, Zive EM, Eappen S. AORN J. 2011;94:590-598.

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

Can aviation-based team training elicit sustainable behavioral change?

Sax HC, Browne P, Mayewski RJ, et al. Arch Surg. 2009;144:1133-1137.

REVIEW

Avoiding wrong site surgery: a systematic review.

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

STUDY

From the flight deck to the operating room: an initial pilot study of the feasibility and potential impact of true interdisciplinary team training using high-fidelity simulation.

Paige J, Kozmenko V, Morgan B, et al. J Surg Educ. 2007;64:369-377.

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.

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