AHRQ Patient Safety Network

PATIENT SAFETY PRIMERS
Safety Culture

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Safety Culture: High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work... Read Full Glossary Entry >

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Safety Target

•Device-related Complications (29)

•Diagnostic Errors (13)

•Identification Errors (16)

•Discontinuities, Gaps, and Hand-Off Problems (39)

•Fatigue and Sleep Deprivation (7)

•Medication Safety (130)

•Medical Complications (96)

•Nonsurgical Procedural Complications (20)

•Surgical Complications (104)

•Transfusion Complications (3)

•Psychological and Social Complications (39)

Origin/Sponsor

•Asia (6)

•Australia and New Zealand (17)

•Central and South America (1)

Resource Types

•Clinical Guideline (1)

•Journal Article (610)

•Legislation/Regulation (10)

•Meeting/Conference (15)

•Newspaper/Magazine Article (91)

•Press Release/Announcement (4)

•Special or Theme Issue (33)

•Tools/Toolkit (13)

•Web Resource (25)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (85)

•Active Errors (68)

•Latent Errors (66)

•Near Miss (17)

Approach to Improving Safety
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Culture of Safety

•Learning Organization (42)

•Red Rules (3)

•Institutional Patient Safety Plan (17)

•Just Culture (26)

Clinical Areas

•Allied Health Services (4)

Target Audience

•Health Care Providers (566)

•Health Care Executives and Administrators (827)

•Non-Health Care Professionals (421)

•Patients (59)

Setting of Care

•Hospitals (536)

•Psychiatric Facilities (3)

•Residential Facilities (25)

•Ambulatory Care (50)

•Outpatient Surgery (5)

•Patient Transport (8)

1 - 20 of 935

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STUDY

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

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

COMMENTARY

Creating a culture of safety by using checklists.

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

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.

COMMENTARY

Mark My Limb.

O'Leary DS, Jacott WE. AHRQ WebM&M [serial online]. December 2004.

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.

STUDY

Can aviation-based team training elicit sustainable behavioral change?

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

NEWSPAPER/MAGAZINE ARTICLE

Wrong body part, wrong patient surgeries continue despite new procedures.

Rojas-Burke J. The Oregonian. May 25, 2011.

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.

COMMENTARY

Retained surgical items and minimally invasive surgery.

Gibbs VC. World J Surg. 2011;35:1532-1539.

COMMENTARY

Improving patient safety: patient-focused, high-reliability team training.

McKeon LM, Cunningham PD, Detty Oswaks JS. J Nurs Care Qual. 2009;24:76-82.

STUDY

Crew resource management improved perception of patient safety in the operating room.

Gore DC, Powell JM, Baer JG, et al. Am J Med Qual. 2010;25:60-63.

BOOK/REPORT

Recommendations for Safe Use of Insulin in Hospitals.

Bethesda, MD: American Society of Health-System Pharmacists; 2006.

SPECIAL OR THEME ISSUE

Quality of Anesthesia Care.

Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.

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.

COMMENTARY

"Managing up" can improve teamwork in the OR.

Smith SL. AORN J. 2010;91:576-582.

STUDY

Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.

Espin S, Levinson W, Regehr G, Baker GR, Lingard L. Surgery. 2006;139:6-14.

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

Incorrect surgical counts: a qualitative analysis.

Rowlands A, Steeves R. AORN J. 2010;92:410-419.

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.

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