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psnet.ahrq.gov/issue/act-performance-exploring-residents-decision-making-processes-seek-help
October 13, 2021 - June 12, 2019
Failure to debrief after critical events in anesthesia is associated with
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psnet.ahrq.gov/issue/contributors-diagnostic-error-or-delay-acute-care-setting-survey-clinical-stakeholders
May 26, 2021 - and Miscommunication among Specialists
March 15, 2023
Accuracy of spinal anesthesia
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psnet.ahrq.gov/issue/5th-national-audit-project-nap5-accidental-awareness-during-general-anaesthesia-patient
October 01, 2014 - every public hospital in the United Kingdom and Ireland regarding accidental patient awareness during anesthesia
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psnet.ahrq.gov/issue/decreased-incidence-cesarean-surgical-site-infection-rate-hospital-wide-perioperative-bundle
September 08, 2021 - WebM&M Cases
Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia
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psnet.ahrq.gov/issue/interventions-targeted-reducing-diagnostic-error-systematic-review
March 10, 2021 - February 9, 2022
Systematic review of intraoperative anesthesia handoffs and handoff
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psnet.ahrq.gov/issue/diagnostic-accuracy-physician-staffed-emergency-medical-teams-retrospective-observational
December 22, 2021 - February 24, 2021
Persisting high rates of omissions during anesthesia induction are
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psnet.ahrq.gov/issue/surgical-programs-veterans-health-administration-maintain-briefing-and-debriefing-following
October 24, 2018 - November 21, 2012
Anesthesia adverse events voluntarily reported in the Veterans Health
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psnet.ahrq.gov/issue/inpatient-suicide-and-suicide-attempts-veterans-affairs-hospitals
January 02, 2017 - January 5, 2017
Developing surgical and anesthesia resident patient safety competencies
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psnet.ahrq.gov/issue/assessment-impact-just-culture-quality-and-safety-us-hospitals
April 13, 2017 - August 28, 2024
Anesthesia-related closed claims in free-standing ambulatory surgery
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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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_build_ssibundle.pptx
December 01, 2017 - Accurate temperature probes
Point of care glucose monitoring
Under-body warmers
Sanitizing wipes near anesthesia … Interventions
Increased amount of gentamicin available in room
Added dose calculator in anesthesia record … Educated surgery, anesthesia, and nursing staff
Intervention
‹#›
Building Your SSI … Standardize selections based on your hospital procedures
Engage surgery, nursing, and anesthesia areas … Do patients get checked beforehand when they go to a pre-anesthesia clinic?
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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.
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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.
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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.
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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
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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).
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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
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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
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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.
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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