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1. Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery | Agency for Healthcare Research and Quality
   www.ahrq.gov/patient-safety/resources/learning-lab/anesthesia-medication-long-desc.html
   January 01, 2025 - Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery Principal Investigator … settings as risk factors for anesthesia medication delivery. 1-4 These findings led to developing anesthesia … “One size” doesn’t “fit all”: understanding variability in anesthesia work practices . … Systems safety in nonoperating room anesthesia locations . … “One size” doesn’t “fit all”: understanding variability in anesthesia work practices .

2. Kaiser Permanente School of Anesthesia Uses AHRQ’s Surveys on Patient Safety Culture®, TeamSTEPPS® | Agency for Healthcare Research and Quality
   www.ahrq.gov/news/newsroom/case-studies/202502.html
   June 01, 2025 - Kaiser Permanente School of Anesthesia Uses AHRQ’s Surveys on Patient Safety Culture®, TeamSTEPPS® … Search All Impact Case Studies June 2025 Kaiser Permanente (KP) School of Anesthesia in Pasadena … Nearly 40 percent of anesthesia practitioners feel rushed when taking care of patients. … About 15 percent of anesthesia practitioners do not feel that their ideas and suggestions are valued … Based on the project results, the Kaiser Permanente School of Anesthesia is improving its TeamSTEPPS

3. Appendix D. Ambulatory Surgery Center Checklist Template - Implementation Guide | Agency for Healthcare Research and Quality
   www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-d.html
   April 01, 2017 - Guide Ambulatory Surgery Checklist - Preop Before Patient Enters Room Nurse, Anesthesia … venous thromboembolism             - Compression boots and/or anticoagulants in place |___| Anesthesia … safety check completed |___| Type of anesthesia |___| Anticipated airway and aspiration risk … Surgeon, Nurse, and Anesthesia Professional perform the Timeout |___| Patient's name |___| Surgical … Briefing Surgeon Shares: |___| Any changes to operative plan and possible difficulties Anesthesia

4. Appendix E. Endoscopy Checklist Template - Implementation Guide | Agency for Healthcare Research and Quality
   www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-e.html
   May 01, 2017 - Safety Checklist - Preprocedure Area/Procedure Room Before Patient Enters Room Nurse, Anesthesia … Known allergies |___| Patient height, weight, body mass index |___| History and physical Anesthesia … Professional and Nurse Discuss: |___| Anesthesia safety check is completed |___| Type of anesthesia … changes to the plan and possible difficulties |___| Necessary equipment/devices are available Anesthesia

5. Generic Dashboard Data 2024 (xls file)
   www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2024.xlsx
   January 01, 2024 - unit) 6,795 6.6% Surgery or Anesthesia Labor and delivery 1,071 1.0% Surgery or Anesthesia Laboratory … 3.8% Surgery or Anesthesia Other area within the facility 9,086 8.8% Surgery or Anesthesia Unknown … 93 0.1% Surgery or Anesthesia Other location 2,404 2.3% Surgery or Anesthesia Outside area (i.e., … Clinical Protocols 88 0.2% Surgery or Anesthesia Staff qualifications 455 1.0% Surgery or Anesthesia … Supervisor/Support 28 0.1% Surgery or Anesthesia Multiple 1,028 2.3% Surgery or Anesthesia Other:

6. Final Progress Report: Unexpected Clinical Events: Impact on Patient Safety (pdf file)
   www.ahrq.gov/sites/default/files/2024-12/weinger2-report.pdf
   January 01, 2024 - Still photos of videotaped anesthesia cases containing NRE. … Some feel intraoperative reading lowers the quality of anesthesia care because, when the anesthesia … Understanding the Post-Anesthesia Extubation Decision. … Weinger MB: Anesthesia incidents and accidents. … Understanding the Post-Anesthesia Extubation Decision.

7. Final Progress Report: Improved Patient Safety Through Web-Based Education (pdf file)
   www.ahrq.gov/sites/default/files/2024-02/hendee-report.pdf
   January 01, 2024 - For the anesthesia module, input from representative of the Anesthesia Patient Safety Foundation was … Associate Professor of Anesthesia, Harvard Medical School Department of Anesthesia and Critical Care … Keating-Christensen: patients and families anticipating anesthesia). … • Introduction • General Overview • Before Anesthesia • After Anesthesia • Anesthesia Safety for … Special Populations & Chronically Ill • Alternative Medicine & Anesthesia • Anesthesia Safety for

8. 115-How-To-Randomly-Order-High-Touch (doc file)
   www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/115-how-to-randomly-order-high-touch.docx
   April 01, 2025 - How To Randomly Order Lists of Rooms (Preoperative, Post-Anesthesia Care Unit, and Operating Room) and … placement is important, to ensure every operating room (OR) and patient area in the preoperative or post-anesthesia … Anesthesia computer mouse OR bed Nurse computer mouse Med cart – handles Nurse computer keyboard OR door … bar or handle Anesthesia chair Patient chart Nurse phone Anesthesia machine gas knobs IV pole Anesthesia … machine computer screen Anesthesia computer keyboard Arm board Surgical light – handle References

9. Normothermia Audit Tool | Agency for Healthcare Research and Quality
   www.ahrq.gov/hai/tools/surgery/tools/surgical-complication-prevention/normothermia-audit.html
   December 01, 2017 - 14: Indicate whether a forced air warmer was used in the period between the time of incision and the anesthesia … The duration can be determined from the difference between anesthesia start time and anesthesia stop … Yes ___        No ___ Temperature on arrival to post-anesthesia care unit/intensive care unit … Anesthesia stop time minus anesthesia start time. _____ hours _____ minutes ICU = intensive … care unit; OR = operating room; PACU = post-anesthesia care unit

10. Tool: Normothermia Audit (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/surgical-complication-prevention/normothermia_audit.docx
    December 01, 2017 - : Indicate whether a forced air warmer was used in the period between the time of incision and the anesthesia … The duration can be determined from the difference between anesthesia start time and anesthesia stop … Temperature on arrival to post-anesthesia care unit/intensive care unit _____ oC or NA 16. … Duration of case Anesthesia stop time minus anesthesia start time _____ hours _____ minutes ICU … = intensive care unit; OR = operating room; PACU = post-anesthesia care unit *Not available **Use of

11. Strategy 2: Communicating to Improve Quality (Tool 3) (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/asc-checklist-template.docx
    January 01, 2009 - Surgery Implementation Guide Ambulatory Surgery Checklist Preop Before Patient Enters Room Nurse, Anesthesia … procedure · Patient position · Known allergies · Patient weight · History and physical Nurse and Anesthesia … safety check completed · Type of anesthesia · Anticipated airway and aspiration risk · Changes in patient … Surgeon, Nurse, and Anesthesia Professional perform the Timeout · Patient’s name · Surgical procedure … Briefing Surgeon Shares: · Any changes to operative plan and possible difficulties Anesthesia Professional

12. Final Progress Report: Reducing the Risk of Preventable Postpartum Lower Extremity Nerve Injuries (pdf file)
    www.ahrq.gov/sites/default/files/2025-03/toledo-report.pdf
    January 01, 2025 - As components of the anesthesia record could not be extracted from the electronic medical record and … The anesthesia record was not available for 12 patients with nerve injuries, so complete data on … Anesthesia Patient Safety Newsletter 2021; 36 (2). … A Century of Progress and Collaboration Between Obstetric Anesthesiologists, Anesthesia & Analgesia … , and the International Anesthesia Research Society.

13. Labor and Delivery Unit Safety: Safe Cesarean Section | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/strategies/labor-delivery-unit/tool-safe-csection.html
    July 01, 2023 - or care teams within a unit, for example transfers between L&D room and OR, and between OR and post-anesthesia … The L&D/OR/neonatal/anesthesia teams maintain a shared mental model for the safe surgery perioperative … provider confirms: ___ Type of anesthesia used (Spinal / Epidural / Combined / General) … provider confirms: ___ Type of anesthesia used (Spinal / Epidural / Combined / General) … provider confirms:    Type of anesthesia used:      ___ Spinal      ___ Epidural      ___ Combined

14. Section 3-C, Tables 2-5 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-120-section-3c-tables-2-5.pdf
    June 02, 2025 - referral center P-value Facility Type Community hospital 61 (58.7%) 207 (91.6%) <0.001 Anesthesia … high-risk referral center P-value Night-time and weekend staffing In-house anesthesiologist or anesthesia … team dedicated to L&D 61 (60.4%) 57 (26.3%) <0.001 In-house anesthesiologist or anesthesia team … Low risk, ≥1500 births per year Low risk, <1500 births per year P- value Recommended anesthesia

15. Tables 2-5 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0121-tables-2-5.pdf
    June 02, 2025 - high-risk referral center P-value Facility Type Community hospital 61 (58.7%) 207 (91.6%) <0.001 Anesthesia … high-risk referral center P-value Night-time and weekend staffing In-house anesthesiologist or anesthesia … team dedicated to L&D 61 (60.4%) 57 (26.3%) <0.001 In-house anesthesiologist or anesthesia team … year Low risk, ≥1500 births per year Low risk, <1500 births per year P- value Recommended anesthesia

16. High-Risk Deliveries at Facilities with 24/7 In-House Blood Banking/Transfusion Services - Tables 2-5 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-0122-tables2-5.pdf
    June 02, 2025 - Facility Type Annual Delivery volume* Community hospital 61 (58.7%) 207 (91.6%) <0.001 Anesthesia … high-risk referral center P-value Night-time and weekend staffing In-house anesthesiologist or anesthesia … team dedicated to L&D 61 (60.4%) 57 (26.3%) <0.001 In-house anesthesiologist or anesthesia team … Low risk, ≥1500 births per year Low risk, <1500 births per year P- value Recommended anesthesia

17. Appendix M. Master Risk Factor List with Final Bolded | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/ssi/ssiapm.html
    April 01, 2018 -   Y   Y   1   intra-op drugs on paper anesthesia record D Electronic 1 Y Y … on paper anesthesia record M Manual not reliably     Temperature on Arrival to PACU … on paper anesthesia record M Electronic not reliably     Peri-Op Glucose <100   Y … intra-op drugs on paper anesthesia record D Manual 0     Outpatient Surgery   Y … on paper anesthesia record M Electronic ?    

18. Strategy 2: Communicating to Improve Quality (Tool 3) (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/endoscopy-checklist-template.docx
    January 01, 2009 - AHRQ Safety Program for Ambulatory Surgery Implementation Guide Before Patient Enters Room Nurse, Anesthesia … matches the consent · Known allergies · Patient height, weight, body mass index · History and physical Anesthesia … Professional and Nurse Discuss: · Anesthesia safety check is completed · Type of anesthesia · Anticipated … Shares: · Any changes to the plan and possible difficulties · Necessary equipment/devices are available Anesthesia

19. Operating Room Briefing and Debriefing Audit Tool | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/or-briefing-audit.html
    December 01, 2017 - Surgery Attending   Anesthesia Attending Surgery Resident Anesthesia Resident Nurse Anesthesia … Surgery Attending         Surgery Resident         Anesthesia Attending …         Anesthesia Resident         Anesthesia Certified Registered Nurse

20. Kaiser Permanente School of Anesthesia Uses AHRQ’s Surveys on Patient Safety Culture, TeamSTEPPS® | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsletters/e-newsletter/956.html
    May 01, 2025 - Kaiser Permanente School of Anesthesia Uses AHRQ’s Surveys on Patient Safety Culture, TeamSTEPPS® … Today’s Headlines: Kaiser Permanente School of Anesthesia Uses AHRQ’s Surveys on Patient Safety Culture … Kaiser Permanente School of Anesthesia Uses AHRQ’s Surveys on Patient Safety Culture, TeamSTEPPS® The … Kaiser Permanente (KP) School of Anesthesia in Pasadena, Calif., uses AHRQ’s  Surveys on Patient Safety … In response to the project results, the KP School of Anesthesia is improving its TeamSTEPPS training