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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/or_briefing_audit.docx
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 Anesthetist
Circulator
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/015-ss-hand-hygiene-periop-fg.docx
April 01, 2025 - Slide 19
Hand Hygiene for Anesthesia
SAY:
It would be remiss not to take a moment to highlight the … challenges associated with hand hygiene among anesthesia team members. … Anesthesia providers come into frequent contact with the patient and their environment. … Even when anesthesia providers know the risk, overcoming it is a challenge. … Overall anesthesia hand hygiene adherence has been reported to be 18 percent.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/transcript-speaking-up.doc
May 01, 2017 - Berry:
“Anesthesia, I’m concerned about the blood pressure. Is something going on?” … Anesthesia:
“Oh it’s fine. I know my job, and it’s fine.” … Anesthesia:
“Look Dr. Berry, I have everything under control here. The blood pressure’s fine.”
Dr. … Could you call for some anesthesia help to come in here right now?”
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/tool_safe-csection.docx
May 01, 2017 - 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)
Antibiotics infused … provider confirms:
Type of anesthesia used (Spinal/Epidural/Combined/General)
Antibiotics infused … Additional instruments needed/anticipated:
|_| Yes |_| No
Anesthesia provider confirms:
Type of anesthesia
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www.ahrq.gov/teamstepps-program/evidence-base/anesthesiology.html
May 01, 2023 - Simulation-based training in anesthesia crisis resource management (ACRM): A decade of experience. … Anesthesia crisis resource management training: Teaching anesthesiologists to handle critical incidents … Implementing a regional anesthesia block nurse team in the perianesthesia care unit increases patient … Nontechnical skills in anesthesia crisis management with repeated exposure to simulation-based education
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www.ahrq.gov/funding/training-grants/grants/active/kawards/Kawdsumdaie.html
October 01, 2014 - Determine the extent to which cognitively impaired individuals who receive isoflurane general anesthesia … functional decline in the year after surgery compared to patients receiving other types of general anesthesia … Quantify the effects of isoflurane anesthesia versus other general or regional anesthesia on the rate
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/116-evaluating-cleaning-data-collection-tool.docx
April 01, 2025 - __________
Environmental Cleaning Supervisor Name: _________________________
High-Touch Surfaces
*Anesthesia … computer mouse
*Operating room bed
*Nurse computer mouse
*Operating room door
*Anesthesia medical cart … (drawer)
Nurse computer keyboard
Operating room door bar or handle
Anesthesia chair
Patient chair
Nurse … phone
Anesthesia machine gas knobs
Intravenous pole
Anesthesia machine computer screen
Anesthesia computer
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_audit_briefing.pptx
December 01, 2017 - surgeon Surgical Resident Anesthesia Attending Anesthesia CRNA Anesthesia Resident Circulator Scrub … 2 4 1 0 0 1 8 Pauses other tasks Attending surgeon Surgical Resident Anesthesia Attending Anesthesia … Circulator
Anesthesia Resident
Anesthesia CRNA
Anesthesia Attending
Surgical Resident
Attending Surgeon … surgeon Surgical Resident Anesthesia Attending Anesthesia CRNA Anesthesia Resident Circulator Scrub … 4 6 1 0 0 9 Contributes Attending surgeon Surgical Resident Anesthesia Attending Anesthesia CRNA Anesthesia
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/10-frontline-provider.pptx
June 01, 2023 - harms
Patient and family education and engagement in perioperative care
Standardized perioperative anesthesia … Senior Executive: List for your institution
Surgeon Champion: List for your institution
Anesthesia … What is the process for the anesthesia provider to follow standardized intraoperative protocol? … ISCR at [Hospital Name] 13
Key Elements Post Anesthesia Care Unit/Postoperative Day 0
Below are examples … of ISCR components that are relevant to the post anesthesia care unit (PACU)/postoperative day 0 work
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www.ahrq.gov/hai/cauti-tools/archived-webinars/preventing-cauti-proc-related-catheter-use-slides.html
December 01, 2017 - Routinely for patients receiving epidural anesthesia/analgesia.
Gould C, et al. … Slide 21
Incidence of POUR after Anesthesia and Analgesia: Systematic Review
Image: Screen shot … of table showing incidences of POUR after anesthesia and analgesia from a number of studies. … analgesia; SA spinal anesthesia; SI/II single injection/intermittent injection. … Lower Risk
Outpatient
Short duration
IVF <750 mL
Local anesthesia
Leads to avoiding IUC
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/58-frontline-presentation-template.docx
June 01, 2023 - stay
Care of [service line] surgery patients is highly variable for:
Preoperative education
Plan for anesthesia … harms
Patient and family education and engagement in perioperative care
Standardized perioperative anesthesia … commitment:
Senior Executive: List for your institution
Surgeon Champion: List for your institution
Anesthesia … What is the process for the anesthesia provider to follow standardized intraoperative protocol? … Slide 13
Key Elements Post Anesthesia Care Unit/Postoperative Day 0
Below are examples of ISCR components
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www.ahrq.gov/hai/tools/surgery/tools/surgical-complication-prevention/antibiotic-audit.html
December 01, 2017 - Question 11: Document the anesthesia stop time. … Question 14: Determine if the length of time between first antibiotic infusion stop time and anesthesia … Question 11: Document the anesthesia stop time. … Question 14: Determine the length of time between first antibiotic infusion stop time and anesthesia … Yes ___ No ___
Anesthesia stop time.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/surgical-complication-prevention/antibiotic_audit.docx
December 01, 2017 - Question 11: Document the anesthesia stop time. … Anesthesia stop time
12. Was cefotetan used as antibiotic prophylaxis? … Question 11: Document the anesthesia stop time. … Anesthesia stop time
12. Was clindamycin or cefotetan used as antibiotic prophylaxis? … What was the length of time between first antibiotic infusion stop and anesthesia stop?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Patey.pdf
January 01, 2004 - Investigations into causes of error in anesthesia have revealed a similar pattern. … Critical incident studies in anesthesia
have found that around 80 percent of reported incidents involve … Explicit
training in nontechnical skills for anesthesia has previously been limited;
however, with … Video of simulated
anesthesia cases showed that even with minimal training of the raters, there were … in each
hospital and the directors of anesthesia training programs were informed about the
study.
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www.ahrq.gov/hai/tools/surgery/modules/implementation/audit-briefing-slides.html
December 01, 2017 - Anesthesia attending.
Surgery resident.
Anesthesia resident.
Nurse.
Anesthesia CRNA. … Anesthesia resident - 78% NP, 0% FP, 22% POT.
Anesthesia CRNA - 22% NP, 0% FP, 78% POT. … Anesthesia attending - 66% NP, 12% FP, 22% POT.
Surgical resident - 10% NP, 40% FP, 50% POT. … Anesthesia resident - 78% NP, 0% DNC, 22% C.
Anesthesia CRNA - 22% NP, 0% DNC, 78% C. … Anesthesia attending - 68% NP, 10% DNC, 22% C.
Surgical resident - 10% NP, 60% DNC, 30% C.
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www.ahrq.gov/topics/outcomes.html
Children’s Center Uses AHRQ-Funded I-PASS Tool to Boost Patient Safety
Kaiser Permanente School of Anesthesia
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www.ahrq.gov/cahps/surveys-guidance/surgical/index.html
March 01, 2025 - specialty care, by incorporating domains that are relevant to surgical care, such as informed consent, anesthesia … surgeon's office Patients' rating of the surgeon Additionally, two measures of patient experience with anesthesia
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www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/briefing-debriefing.html
December 01, 2017 - Start with “Before Induction of Anesthesia.” Then, go to “Before Skin Incision.” … Through Collective Sensemaking Tool in the AHRQ Toolkit to Promote Safe Surgery
Before Induction of Anesthesia … steps, operative duration, anticipated blood loss
Separation of clean and dirty instruments
Anesthesia … , indicate not applicable (N/A):___________
Attending surgeon: ________________________________
Anesthesia
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/briefing_debriefing.docx
December 01, 2017 - Start with “Before Induction of Anesthesia.” Then, go to “Before Skin Incision.” … Before Induction of Anesthesia
SIGN IN
· Patient has confirmed:
· Identity (name and date of birth … unexpected steps, operative duration, anticipated blood loss
· Separation of clean and dirty instruments
· Anesthesia … comments, indicate not applicable (N/A):___________
· Attending surgeon:
___________________________
· Anesthesia
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh65-67.html
April 01, 2018 - Intercept
-6.27
-3.13
0.0025
Charlson score *
0.32
2.03
0.0423
General anesthesia … Intercept
-3.76
-2.23
0.0256
Charlson score *
-0.51
-1.75
0.0793
General anesthesia … Intercept
-4.57
-3.79
0.0002
Charlson score *
0.03
0.19
0.8475
General anesthesia