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psnet.ahrq.gov/node/49445/psn-pdf
May 01, 2004 - No Blood, Please
May 1, 2004
Liang BA. No Blood, Please. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/no-blood-please
The Case
A young woman, about 30 years of age, was injured in an automobile collision. She was brought to the
emergency department (ED) via ambulance, where she was found to be suffering …
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psnet.ahrq.gov/node/33590/psn-pdf
September 15, 2024 - A 2013 review found that high-performing hospitals—defined as
those ranking highly on objective measures
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psnet.ahrq.gov/node/33570/psn-pdf
June 15, 2024 - errors may be prevented by systems to mitigate the effect of these biases and provide
physicians with objective
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psnet.ahrq.gov/issue/preventable-errors-operating-room-retained-foreign-bodies-after-surgery-part-i
April 28, 2021 - Review
Preventable errors in the operating room: retained foreign bodies after surgery--part I.
Citation Text:
Gibbs VC, Coakley FD, Reines D. Preventable errors in the operating room: retained foreign bodies after surgery--Part I. Curr Probl Surg. 2007;44(5):281-337.
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…
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psnet.ahrq.gov/issue/trauma-when-theres-no-time-count
April 20, 2016 - May 19, 2021
Responses of physicians to an objective safety and quality knowledge test
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psnet.ahrq.gov/issue/unintentionally-retained-guidewires-descriptive-study-73-sentinel-events
April 27, 2019 - Study
Unintentionally retained guidewires: a descriptive study of 73 sentinel events.
Citation Text:
Steelman VM, Thenuwara K, Shaw C, et al. Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events. Jt Comm J Qual Saf. 2019;45(2):81-90. doi:10.1016/j.jcjq.2018.08.0…
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psnet.ahrq.gov/issue/surgical-complications-disclosing-adverse-events-and-medical-errors
September 23, 2020 - Commentary
Surgical complications: disclosing adverse events and medical errors.
Citation Text:
Wang AS, Eisen DB. Surgical complications: disclosing adverse events and medical errors. J Am Acad Dermatol. 2013;68(1):144-6. doi:10.1016/j.jaad.2012.09.008.
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Format:
…
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psnet.ahrq.gov/web-mm/no-blood-please
January 14, 2011 - No Blood, Please
Citation Text:
Liang BA. No Blood, Please. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/issue/improving-safety-operating-room-systematic-literature-review-retained-surgical-sponges
March 05, 2025 - Review
Improving safety in the operating room: a systematic literature review of retained surgical sponges.
Citation Text:
Wan W, Le T, Riskin L, et al. Improving safety in the operating room: a systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol. 2009;22(…
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psnet.ahrq.gov/issue/designing-safer-process-prevent-retained-surgical-sponges-healthcare-failure-mode-and-effect
April 27, 2019 - Study
Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis.
Citation Text:
Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J. 2011;94(2):1…
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psnet.ahrq.gov/issue/application-engineering-problem-solving-methodology-address-persistent-problems-patient
March 18, 2020 - Study
Application of an engineering problem-solving methodology to address persistent problems in patient safety: a case study on retained surgical sponges after surgery.
Citation Text:
Anderson DE, Watts B. Application of an engineering problem-solving methodology to address persistent…
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psnet.ahrq.gov/node/33786/psn-pdf
May 01, 2015 - seen increased interest in developing validated
assessment tools, which should lay a foundation for objective
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psnet.ahrq.gov/node/36247/psn-pdf
February 13, 2008 - Counting for patient safety.
February 13, 2008
Watson DS. Counting for patient safety. AORN J. 2006;84(2):273-5.
https://psnet.ahrq.gov/issue/counting-patient-safety
The author discusses recommended policies and practices for minimizing the risk of retained foreign
objects.
https://psnet.ahrq.gov/issue/counting-p…
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psnet.ahrq.gov/issue/prevalence-and-characteristics-interruptions-and-distractions-during-surgical-counts
March 09, 2016 - Study
Prevalence and characteristics of interruptions and distractions during surgical counts.
Citation Text:
Bubric KA, Biesbroek SL, Laberge JC, et al. Prevalence and characteristics of interruptions and distractions during surgical counts. Jt Comm J Qual Patient Saf. 2021;47(9):556-56…
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psnet.ahrq.gov/issue/risk-factors-retained-surgical-items-meta-analysis-and-proposed-risk-stratification-system
January 18, 2013 - Study
Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system.
Citation Text:
Moffatt-Bruce SD, Cook CH, Steinberg SM, et al. Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. J Surg Res. 2014;190(…
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psnet.ahrq.gov/node/35406/psn-pdf
September 10, 2009 - Maintain accountability in patient safety efforts.
September 10, 2009
Spath P. Maintain accountability in patient safety efforts. Hospital peer review. 2005;30(9):129-32.
https://psnet.ahrq.gov/issue/maintain-accountability-patient-safety-efforts
To develop an accountability initiative, the author recommends settin…
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psnet.ahrq.gov/node/35288/psn-pdf
September 12, 2016 - M.R.I.'s strong magnets cited in accidents.
September 12, 2016
McNeil DG, Jr.
https://psnet.ahrq.gov/issue/mris-strong-magnets-cited-accidents
This front page article in The New York Times reviews flying object incidents in magnetic resonance
imaging (MRI) scanners. A number of dramatic cases are described (includ…
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psnet.ahrq.gov/issue/prevention-retained-surgical-sponges-decision-analytic-model-predicting-relative-cost
January 04, 2010 - Study
Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness.
Citation Text:
Regenbogen SE, Greenberg CC, Resch SC, et al. Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness. Surger…
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psnet.ahrq.gov/node/39801/psn-pdf
December 21, 2014 - Gossypiboma: tales of lost sponges and lessons learned.
December 21, 2014
McIntyre LK. Gossypiboma. Archives of Surgery. 2010;145(8). doi:10.1001/archsurg.2010.152.
https://psnet.ahrq.gov/issue/gossypiboma-tales-lost-sponges-and-lessons-learned
This study describes successful efforts to reduce retained surgical spo…
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psnet.ahrq.gov/node/40814/psn-pdf
September 28, 2011 - Retained surgical items and minimally invasive surgery.
September 28, 2011
Gibbs VC. Retained surgical items and minimally invasive surgery. World J Surg. 2011;35(7):1532-9.
doi:10.1007/s00268-011-1060-4.
https://psnet.ahrq.gov/issue/retained-surgical-items-and-minimally-invasive-surgery
This commentary discusses …