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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. Final Progress Report: Identifying and Reducing Errors in Perioperative Anesthesia Medication Delivery (pdf file)
   www.ahrq.gov/sites/default/files/2025-02/catchpole2-report.pdf
   January 01, 2025 - of anesthesia could or should be standardized. … CONTEXT: Operating Room vs Non-Operating Room Anesthesia Non-operating room anesthesia (NORA) describes … CONTEXT: Workspace Design Guidelines Current standard anesthesia workspace layouts result in anesthesia … • Identify and demarcate a distinct anesthesia zone with adequate space for the anesthesia provider … The anesthesia workspace should be located in a demarcated and distinct anesthesia zone with adequate

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. Patient Safety Concerns Dashboard (xls file)
   www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2019.xlsx
   January 01, 2019 - Death 0.1% 438 Surgery or Anesthesia Severe Harm 0.1% 445 Surgery or Anesthesia Moderate Harm 0.5% … 2,820 Surgery or Anesthesia Mild Harm 2.2% 13,726 Surgery or Anesthesia No Harm 3.0% 18,967 Surgery … Unknown Harm 1.4% 511 Surgery or Anesthesia Death 1.2% 438 Surgery or Anesthesia Severe Harm 1.2% … 445 Surgery or Anesthesia Moderate Harm 7.6% 2,820 Surgery or Anesthesia Mild Harm 37.2% 13,726 Surgery … No Harm 5.2% 18,967 Surgery or Anesthesia Mild Harm 6.1% 13,726 Surgery or Anesthesia Moderate Harm

7. Generic Dashboard Data 2023 (xls file)
   www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2023.xlsx
   January 01, 2023 - ) 79 105,949 0.1% Surgery or Anesthesia Outpatient care area 2,678 105,949 2.5% Surgery or Anesthesia … 0.3% Surgery or Anesthesia Pharmacy 46 105,949 0.0% Surgery or Anesthesia Unknown 91 105,949 0.1% … /Support 42 52,719 0.1% Surgery or Anesthesia Mulitple 1,550 52,719 2.9% Surgery or Anesthesia Human … Factors 1,403 52,719 2.7% Surgery or Anesthesia Environment 158 52,719 0.3% Surgery or Anesthesia … Harm 940 3,026 31.1% Surgery or Anesthesia Under 18 Unknown Death 4 214 1.9% Surgery or Anesthesia

8. 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

9. Patient Safety Concerns Dashboard (xls file)
   www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2022.xlsx
   January 01, 2022 - No Harm 40.6% 39,833 1,567,355 Surgery or Anesthesia Mild Harm 24.5% 24,048 1,567,355 Surgery or Anesthesia … Moderate Harm 4.9% 4,804 1,567,355 Surgery or Anesthesia Severe Harm 0.9% 860 1,567,355 Surgery or … Anesthesia Death 0.8% 818 1,567,355 Surgery or Anesthesia Unknown Harm 28.3% 27,797 1,567,355 Other … No Harm 5.2% 39,833 1,567,355 Surgery or Anesthesia Mild Harm 6.0% 24,048 1,567,355 Surgery or Anesthesia … or Anesthesia Death 10.3% 818 1,567,355 Surgery or Anesthesia Unknown Harm 8.1% 27,797 1,567,355 Other

10. Patient Safety Concerns Dashboard (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2021.xlsx
    January 01, 2021 - No Harm 36.0% 29,592 1,267,662 Surgery or Anesthesia Mild Harm 25.6% 21,018 1,267,662 Surgery or Anesthesia … Moderate Harm 5.2% 4,273 1,267,662 Surgery or Anesthesia Severe Harm 0.8% 636 1,267,662 Surgery or … Anesthesia Death 0.8% 631 1,267,662 Surgery or Anesthesia Unknown Harm 31.6% 25,948 1,267,662 Other … No Harm 5.4% 29,592 1,267,662 Surgery or Anesthesia Mild Harm 6.0% 21,018 1,267,662 Surgery or Anesthesia … or Anesthesia Death 11.3% 631 1,267,662 Surgery or Anesthesia Unknown Harm 7.9% 25,948 1,267,662 Other

11. Patient Safety Concerns Dashboard (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Generic_Dashboard_Data_2020.xlsx
    January 01, 2020 - No Harm 45.4% 28,208 1,075,547 Surgery or Anesthesia Mild Harm 32.8% 20,337 1,075,547 Surgery or Anesthesia … Moderate Harm 6.3% 3,913 1,075,547 Surgery or Anesthesia Severe Harm 1.0% 598 1,075,547 Surgery or … Anesthesia Death 1.0% 615 1,075,547 Surgery or Anesthesia Unknown Harm 13.6% 8,422 1,075,547 Other … No Harm 5.4% 28,208 1,075,547 Surgery or Anesthesia Mild Harm 5.9% 20,337 1,075,547 Surgery or Anesthesia … or Anesthesia Death 11.1% 615 1,075,547 Surgery or Anesthesia Unknown Harm 5.2% 8,422 1,075,547 Other

12. 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.

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

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. 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 ?