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2081. A quality initiative to decrease pathology specimen-labeling errors using radiofrequency identification in a high-volume endoscopy center. | PSNet
      psnet.ahrq.gov/issue/quality-initiative-decrease-pathology-specimen-labeling-errors-using-radiofrequency
      August 28, 2017 - October 27, 2022 Safety in office-based anesthesia: an updated review of the literature

2082. Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries. | PSNet
      psnet.ahrq.gov/issue/global-patient-outcomes-after-elective-surgery-prospective-cohort-study-27-low-middle-and
      January 23, 2019 - January 23, 2019 Persisting high rates of omissions during anesthesia induction are decreased

2083. Liability reform should make patients safer: "Avoidable classes of events" are a key improvement. | PSNet
      psnet.ahrq.gov/issue/liability-reform-should-make-patients-safer-avoidable-classes-events-are-key-improvement
      July 26, 2023 - to develop a list of uniformly accepted "avoidable classes of events," such as paralysis following anesthesia

2084. Wrong-side thoracentesis: lessons learned from root cause analysis. | PSNet
      psnet.ahrq.gov/issue/wrong-side-thoracentesis-lessons-learned-root-cause-analysis
      July 16, 2015 - October 24, 2018 Anesthesia adverse events voluntarily reported in the Veterans Health

2085. Is oral chemotherapy prescription safe for patients? A cross-sectional survey. | PSNet
      psnet.ahrq.gov/issue/oral-chemotherapy-prescription-safe-patients-cross-sectional-survey
      May 18, 2022 - October 20, 2021 Failure to debrief after critical events in anesthesia is associated

2086. "Please describe from your point of view a typical case of an error in palliative care": qualitative data from an exploratory cross-sectional survey study among palliative care professionals. | PSNet
      psnet.ahrq.gov/issue/please-describe-your-point-view-typical-case-error-palliative-care-qualitative-data
      December 04, 2016 - Harm November 1, 2017 Situation awareness errors in anesthesia and critical

2087. Examining the meaning of the language used to communicate the nursing hand-off. | PSNet
      psnet.ahrq.gov/issue/examining-meaning-language-used-communicate-nursing-hand
      July 07, 2021 - July 7, 2021 Intraoperative patient information handover between anesthesia providers

2088. Beyond the surgical safety checklist: using intraoperative handoff to facilitate team situation awareness in the OR. | PSNet
      psnet.ahrq.gov/issue/beyond-surgical-safety-checklist-using-intraoperative-handoff-facilitate-team-situation
      June 13, 2018 - More About The Topic Operating Room Anesthesiology Surgery Medical/Surgical Nursing Anesthesia

2089. Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error. | PSNet
      psnet.ahrq.gov/issue/hastened-death-due-disease-burden-and-distress-has-not-received-timely-quality-palliative
      October 31, 2023 - A retrospective analysis demonstrates that a failure to document key comorbid diseases in the anesthesia

2090. Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s largest event reporting database. | PSNet
      psnet.ahrq.gov/issue/patient-safety-trends-2021-analysis-288882-serious-events-and-incidents-nations-largest-event
      May 19, 2021 - September 8, 2021 Outcomes from Wake Up Safe, the pediatric anesthesia quality improvement

2091. Secured But Not Always Safe | PSNet
      psnet.ahrq.gov/web-mm/secured-not-always-safe
      October 01, 2015 - She received spinal anesthesia, and the airway was maintained with the use of a laryngeal mask airway … This unusual case of mediastinitis, which temporally followed the use of laryngeal mask airway (LMA) anesthesia … this way, it may provide additional safety over the positive pressure ventilation used in "general anesthesia … During standard preoperative consenting, the anesthesia team discusses the general approach to anesthesia … Such events should reinforce the importance of a comprehensive and vigilant approach to anesthesia care

2092. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49731/psn-pdf
      April 01, 2015 - The percentage of OR fires increased over time, from less than 1% of all surgical anesthesia claims … in 1985–1994 to 4.4% of all surgical anesthesia claims between 2000–2009.(7) This trend was especially … pronounced among claims for monitored anesthesia. … If heavy sedation with supplemental oxygen is required, the ASA advisory recommends general anesthesia … Anesthesia Patient Safety Foundation, Fire Safety Video. [Available at] 4.

2093. Center for Patient Safety. | PSNet
      psnet.ahrq.gov/issue/center-patient-safety
      May 01, 2016 - September 20, 2023 Outcomes from Wake Up Safe, the pediatric anesthesia quality improvement … January 21, 2021 Anesthesia Awareness Registry. … March 17, 2011 WebAIRS Anesthesia Incident Reporting System.

2094. Perioperative Safety Culture: Principles, Practices, and Pragmatic Approaches. | PSNet
      psnet.ahrq.gov/issue/perioperative-safety-culture-principles-practices-and-pragmatic-approaches
      January 23, 2013 - January 23, 2013 Quality of Anesthesia Care.  … December 15, 2021 Safety and Quality in Perioperative Anesthesia Care. … April 7, 2021 Quality of Anesthesia Care. 

2095. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33892/psn-pdf
      May 03, 2016 - This technique, used in anesthesia to understand failures (see also Cooper et al. 1978 and Flanagan … psnet.ahrq.gov/issue/critical-incident-technique-bibliography-2001 https://psnet.ahrq.gov/issue/preventable-anesthesia-mishaps-study-human-factors

2096. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.311_slideshow.ppt
      December 01, 2013 - Thrombolysis. 2013;36:212-222. http://www.ncbi.nlm.nih.gov/pubmed/23532364 14 TSOACs and Neuraxial Anesthesia … Patients undergoing neuraxial anesthesia (such as the epidural catheter in this case) are at risk for … (2) Recent guidelines from the American Society of Regional Anesthesia and Pain Medicine recommend that … Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society … of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition).

2097. Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps. | PSNet
      psnet.ahrq.gov/issue/key-vulnerabilities-surgical-environment-container-mix-ups-and-syringe-swaps
      June 10, 2018 - November 29, 2017 View More Related Resources Anesthesia Patient … Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia … May 3, 2006 WebM&M Cases Unexplained Apnea Under Anesthesia

2098. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46442/psn-pdf
      October 04, 2017 - This special issue focuses on transfers involving anesthesia care. … psnet.ahrq.gov/issue/inadequate-hand-communication https://psnet.ahrq.gov/issue/intraoperative-handoffs-among-anesthesia-providers-increase-incidence-documentation-errors

2099. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34754/psn-pdf
      February 06, 2018 - He and Morell are well suited to be at the helm of the first anesthesia textbook on patient safety.

2100. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35116/psn-pdf
      April 06, 2011 - crises-clinical-care-approach-management This commentary discusses the many facets of crisis management in anesthesia … This commentary is accompanied by a manual of 24 specific sub-algorithms in anesthesia crisis management