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2061. Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
      January 01, 2023 - General Anesthesia: “A drug-induced loss of consciousness during which patients are not arousable, even … Anesthesiologists (ASA) Physical Status Classification System was created in 1962 to assess patients’ pre-anesthesia … Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the

2062. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. | PSNet
      psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
      January 23, 2017 - General Anesthesia: “A drug-induced loss of consciousness during which patients are not arousable, even … Anesthesiologists (ASA) Physical Status Classification System was created in 1962 to assess patients’ pre-anesthesia … Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the

2063. Death by PCA | PSNet
      psnet.ahrq.gov/web-mm/death-pca
      January 06, 2017 - Two hours after delivery, the post-anesthesia care unit (PACU) nurse removed the patient's epidural catheter … Thus, confirmation bias ( 9 ) likely occurred with the post-anesthesia care unit (PACU) nurses.

2064. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-01/final_spotlight_near_miss_transfusion_01082020_tocme.pdf
      January 01, 2020 - • Patient was seen by surgical and anesthesia teams in the preoperative holding area the morning

2065. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.72_slideshow.ppt
      September 01, 2004 - The patient was taken to the operating room for resection under general anesthesia.

2066. Checklists | PSNet
      psnet.ahrq.gov/primer/checklists
      September 15, 2024 - implementation of a  surgical safety checklist , which included specific steps during induction of anesthesia

2067. Dangerous Shift | PSNet
      psnet.ahrq.gov/web-mm/dangerous-shift
      July 24, 2013 - An example of this approach is the Post Anesthesia Care Unit (PACU) Dashboard developed by Massachusetts … Critical incidents associated with intraoperative exchanges of anesthesia personnel.

2068. Transfer Troubles | PSNet
      psnet.ahrq.gov/web-mm/transfer-troubles
      December 29, 2014 - During induction of anesthesia, the patient rapidly became hypotensive and required vasopressors. … following her operation on hospital day 2, medical records arrived from the referring hospital and the anesthesia

2069. A Painful Medication Reconciliation Mishap | PSNet
      psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
      May 01, 2008 - pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia … and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia,

2070. Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
      January 01, 2023 - • The patient recovered in the Post-Anesthesia Care Unit (PACU) overnight, was evaluated by physical … Surgical and anesthesia teams should work together, as hematoma evacuation may be required prior to

2071. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. | PSNet
      psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
      June 28, 2023 - WebM&M Cases Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia … WebM&M Cases Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia

2072. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. | PSNet
      psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
      March 15, 2023 - The procedure was performed under general anesthesia, by an attending physician and a fellow, without … Medications provided to induce various levels of sedation (from light to general anesthesia) can have

2073. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848108/psn-pdf
      April 26, 2023 - General Anesthesia: “A drug-induced loss of consciousness during which patients are not arousable, even … Anesthesiologists (ASA) Physical Status Classification System was created in 1962 to assess patients’ pre- anesthesia … Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the

2074. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33571/psn-pdf
      March 15, 2025 - settings, such as the Intensive Care Unit Safety Reporting System and systems for reporting surgical and anesthesia-related

2075. In Conversation With… Dave deBronkart | PSNet
      psnet.ahrq.gov/perspective/conversation-dave-debronkart
      June 01, 2014 - like the 1975 Congressional hearings on unnecessary surgery and ABC's 1982 "The Deep Sleep" special on anesthesia … National Patient Safety Foundation (NPSF), an attempt to duplicate for mainstream medicine the success the Anesthesia … Anesthesia Patient Safety Foundation Newsletter. Spring 2007;22. [Available at] 5.

2076. In Conversation With… Mark Graban, MS, MBA | PSNet
      psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
      January 01, 2015 - There had been a longstanding history of using regional anesthesia to block the pain signals as they … Care must be taken, however, to use only the minimum effective amount of anesthesia in order to avoid … the emergency department, get admitted to the floor, and then get worked up by medicine, surgery, and anesthesia

2077. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care | PSNet
      psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
      January 01, 2015 - There had been a longstanding history of using regional anesthesia to block the pain signals as they … Care must be taken, however, to use only the minimum effective amount of anesthesia in order to avoid … the emergency department, get admitted to the floor, and then get worked up by medicine, surgery, and anesthesia

2078. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.33_slideshow.ppt
      October 01, 2003 - After the patient was intubated for general anesthesia, the trainee reviewed her chart and noted that

2079. No Blood, Please | PSNet
      psnet.ahrq.gov/web-mm/no-blood-please
      January 14, 2011 - Many providers, such as emergency department, laboratory medicine, and anesthesia staff, will likely

2080. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49464/psn-pdf
      December 27, 2020 - Most patients are given supplemental oxygen as part of anesthesia.