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541. An observational study of practice during transfer of patients from anaesthetic room to operating theatre. | PSNet
     psnet.ahrq.gov/issue/observational-study-practice-during-transfer-patients-anaesthetic-room-operating-theatre
     September 27, 2016 - Dilute: Drug Errors and Consequences in the Operating Room October 27, 2021 An anesthesia … exchange, knowledge of critical information, perception of safety, and possibly perception of teamwork in anesthesia … December 23, 2012 Analysis of deaths related to anesthesia in the period 1996-2004 from … March 28, 2011 Injury and liability associated with monitored anesthesia care: a closed

542. In Conversation with...Lucian Leape, MD | PSNet
     psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
     August 01, 2006 - When I landed in the Anesthesia Bioengineering Unit at the Massachusetts General Hospital in 1972, I … My lecture was entitled, "The Anesthesia Machine: An Accident Waiting to Happen." … Jeep was Chairman of the Anesthesia Department at what was then the Deaconess Hospital and, in 1983, … Preventable anesthesia mishaps: a study of human factors. Anesthesiology. 1978;49:399-406. … Critical incidents associated with intraoperative exchanges of anesthesia personnel.

543. Fire in the Hole!—An OR Fire | PSNet
     psnet.ahrq.gov/web-mm/fire-hole-or-fire
     August 03, 2017 - OR Fires in Malpractice Claims Using the Anesthesia Closed Claims database, we reviewed 103 closed … 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. … Anesthesia Patient Safety Foundation, Fire Safety Video. [Available at] 4.

544. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49848/psn-pdf
     January 01, 2019 - After induction of general anesthesia, the patient could be ventilated but her trachea could not be … and an oral tumor mass at the base of the tongue was booked for a biopsy of this mass under general anesthesia … The anesthesiologist induced general anesthesia, but laryngoscopy and intubation proved extremely difficult … Miller's Anesthesia. 8th ed. Philadelphia, PA: Saunders: 2013;1647-1683. IBSN: 9780702052835. 6. … Emergency manual implementation in a large academic anesthesia practice: strategy and improvement in

545. Risk factors for adverse events in emergency department procedural sedation for children. | PSNet
     psnet.ahrq.gov/issue/risk-factors-adverse-events-emergency-department-procedural-sedation-children
     January 19, 2014 - September 19, 2013 Incidence and nature of adverse events during pediatric sedation/anesthesia … April 11, 2011 The incidence and nature of adverse events during pediatric sedation/anesthesia … March 1, 2023 Increasing compliance of safe medication administration in pediatric anesthesia … June 19, 2019 Medication errors in pediatric anesthesia: a report from the Wake Up Safe

546. When do supervising physicians decide to entrust residents with unsupervised tasks? | PSNet
     psnet.ahrq.gov/issue/when-do-supervising-physicians-decide-entrust-residents-unsupervised-tasks
     October 03, 2012 - June 14, 2023 Failure to debrief after critical events in anesthesia is associated with … April 11, 2018 Simulation in obstetric anesthesia. … January 4, 2012 An objective methodology for task analysis and workload assessment in anesthesia … May 31, 2011 Management of anesthesia equipment failure: a simulation-based resident

547. Improving anesthesiologists' ability to speak up in the operating room: a randomized controlled experiment of a simulation-based intervention and a qualitative analysis of hurdles and enablers. | PSNet
     psnet.ahrq.gov/issue/improving-anesthesiologists-ability-speak-operating-room-randomized-controlled-experiment
     June 15, 2012 - November 18, 2020 An anesthesia preinduction checklist to improve information exchange … , knowledge of critical information, perception of safety, and possibly perception of teamwork in anesthesia … April 16, 2018 An embedded checklist in the Anesthesia Information Management System … June 15, 2011 Management of anesthesia equipment failure: a simulation-based resident

548. Inter-professional clinical handover in post-anaesthetic care units: tools to improve quality and safety. | PSNet
     psnet.ahrq.gov/issue/inter-professional-clinical-handover-post-anaesthetic-care-units-tools-improve-quality-and
     April 24, 2013 - View More Related Resources Failure to debrief after critical events in anesthesia … February 13, 2019 Assessing the impact of the anesthesia medication template on medication … errors during anesthesia: a prospective study. … February 1, 2013 Barriers to adverse event and error reporting in anesthesia.

549. Reporting of perioperative adverse events by pediatric anesthesiologists at a tertiary children's hospital: targeted interventions to increase the rate of reporting. | PSNet
     psnet.ahrq.gov/issue/reporting-perioperative-adverse-events-pediatric-anesthesiologists-tertiary-childrens
     April 24, 2018 - June 21, 2015 View More Related Resources Perspectives on anesthesia … Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia … September 1, 2021 Complications associated with the anesthesia transport of pediatric … July 31, 2019 Frequency of medication error in pediatric anesthesia: a systematic review

550. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49512/psn-pdf
     May 01, 2006 - A prompt examination of both of the patient's ankles under anesthesia did not demonstrate any clinical … The spinal anesthesia was reversed, and the patient was returned to her room and fortunately did not … The final set of errors occurred prior to the patient receiving spinal anesthesia. … This patient was subjected to spinal anesthesia for no reason. … Complications of spinal and epidural anesthesia. Anesthesiol Clin North America. 2000;18:461-485.

551. 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

552. 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.

553. 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.

554. 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. 

555. 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

556. 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).

557. 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

558. 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

559. 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.

560. 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