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381. Power and conflict: the effect of a superior's interpersonal behaviour on trainees' ability to challenge authority during a simulated airway emergency. | PSNet
     psnet.ahrq.gov/issue/power-and-conflict-effect-superiors-interpersonal-behaviour-trainees-ability-challenge
     December 13, 2017 - June 28, 2017 The impact of hindsight bias on the diagnosis of perioperative events by anesthesia

382. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. | PSNet
     psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
     October 24, 2018 - November 21, 2012 Anesthesia adverse events voluntarily reported in the Veterans Health

383. Assessment of the implementation of a national patient safety alert to reduce wrong site surgery. | PSNet
     psnet.ahrq.gov/issue/assessment-implementation-national-patient-safety-alert-reduce-wrong-site-surgery
     March 28, 2011 - May 8, 2024 Developing surgical and anesthesia resident patient safety competencies through

384. 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

385. Coming Up Short: Maintaining Safety in the Face of Drug Shortages | PSNet
     psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
     November 01, 2012 - of 300 respondents, 87% reported that the shortages impacted emergency care, 85% reported effects on anesthesia … February 1, 2023 Complications associated with the anesthesia transport of pediatric

386. Code Blue—Where To? | PSNet
     psnet.ahrq.gov/web-mm/code-blue-where
     March 30, 2020 - Thus, the "code team" (comprised of a senior medical resident, medical intern, anesthesia resident, anesthesia

387. Silent Pain in the Neck | PSNet
     psnet.ahrq.gov/web-mm/silent-pain-neck
     August 19, 2020 - of post-CEA hematoma formation include non-reversal of heparin, intraoperative hypotension, general anesthesia … Director, Critical Care Fellowship Associate Director, Surgical Intensive Care Unit Department of Anesthesia

388. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33572/psn-pdf
     December 15, 2024 - implementation of a surgical safety checklist, which included specific steps during induction of anesthesia

389. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough | PSNet
     psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
     September 01, 2003 - At the handoff to the post-anesthesia care unit (PACU) nurse, the OR nurse stated that there was packing … into the vagina in the OR or procedural area, where the patient is likely sedated or under general anesthesia … WebM&M Cases Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia

390. Caution, Interrupted | PSNet
     psnet.ahrq.gov/web-mm/caution-interrupted
     October 01, 2016 - A 50 ml bottle of Diprivan (propofol, an intravenous sedative-hypnotic commonly used in anesthesia) that … 1, 2003 WebM&M Cases Unexplained Apnea Under Anesthesia

391. Poor Prognosis | PSNet
     psnet.ahrq.gov/web-mm/poor-prognosis
     March 15, 2016 - The patient was taken to the operating room for resection under general anesthesia. … August 28, 2024 The role of anesthesia in surgical mortality.

392. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49687/psn-pdf
     August 21, 2013 - between ward and intensive care, involving higher levels of monitoring and nursing care but without anesthesia … increased awareness of the risk of sudden deterioration of this patient's condition on induction of anesthesia

393. 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

394. 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

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

396. 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

397. Patient Safety Events Involving Opioid Dose Stacking | PSNet
     psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
     July 08, 2022 - Evaluation of a Standardized Sedation Assessment for Opioid Administration in the Post Anesthesia Care … Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia

398. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy | PSNet
     psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
     September 30, 2020 - obstetric hemorrhage simulation should be interdisciplinary and interprofessional (e.g., obstetrics, anesthesia … WebM&M Cases Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia

399. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy | PSNet
     psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
     April 08, 2019 - : Clinical and Educational Uses May 1, 2015 Analysis of deaths related to anesthesia … June 19, 2024 Peer support and second victim programs for anesthesia professionals involved

400. 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.