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psnet.ahrq.gov/issue/changes-hospital-acquired-conditions-and-mortality-associated-hospital-acquired-condition
July 24, 2019 - January 4, 2012
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Hospitals
Operating … Room
Quality and Safety Professionals
Surgery
Nosocomial Infections
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psnet.ahrq.gov/issue/triggers-contributing-health-care-clinicians-disruptive-behaviors
June 24, 2020 - September 9, 2020
Improving transfusion safety in the operating room with a barcode scanning
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psnet.ahrq.gov/issue/meta-review-methods-measuring-and-monitoring-safety-primary-care
November 03, 2021 - February 24, 2021
Are operating room distractions, interruptions, and disruptions associated
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psnet.ahrq.gov/issue/learning-excellence-healthcare-new-approach-incident-reporting
August 31, 2022 - June 2, 2021
Surgeons' non-technical skills in the operating room: reliability testing
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psnet.ahrq.gov/issue/towards-framework-managing-risk-associated-technology-induced-error
May 10, 2013 - September 11, 2019
From box ticking to the black box: the evolution of operating room
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psnet.ahrq.gov/web-mm/magnetic-deflection
November 18, 2016 - Essentially functioning as a "red rule," similar to how operating room nurses ensure that all are properly
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
January 01, 2023 - She was taken emergently to the operating room for
hematoma evacuation. … elapsed minutes since respiratory arrest.13
• In Case #2, there was time to safely transport to the operating … room to treat in a
controlled environment. … coordinated effort to evacuate the
hematoma and secure the airway in the controlled environment of the
operating … room.
20
Approach to Improving Safety and Patient Safety Target (5)
• The first case additionally
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psnet.ahrq.gov/web-mm/transfer-troubles
December 29, 2014 - They had taken her to the operating room, but she developed low blood pressure before the case and the … Early the next day, the patient was taken to the operating room for surgical repair of her hip fracture … 2003
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Emergency Departments
Operating … Room
Health Care Providers
Quality and Safety Professionals
Gynecology
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psnet.ahrq.gov/node/49413/psn-pdf
September 01, 2003 - Operating room training and team management skill development may be
necessary here (eg, institution … Denver, Colorado: Association of operating room nurses; 2000:213-219.
9.
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - room events reported by the primary clinicians when directly queried by a researcher (nearly 90% were … ., unpublished work), communication or coordination issues played a role in about 11% of 118 actual operating … room events captured during more than 700 hours of direct observation and videotaping. … room, may find her skills lacking when trying to manage a difficult airway in a remote location with … room environment.
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psnet.ahrq.gov/node/39947/psn-pdf
July 03, 2014 - association-between-implementation-medical-team-training-program-and-
surgical-mortality
Classic studies have demonstrated that operating … rooms are rife with communication and teamwork
problems, and suboptimal teamwork has been linked to
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psnet.ahrq.gov/web-mm/patient-mix
December 01, 2007 - (Seeking ways to reduce mix-ups in the operating room; better communication is one remedy, medical experts
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psnet.ahrq.gov/issue/theme-issue-medical-error
October 01, 2024 - Special or Theme Issue
Theme Issue on Medical Error.
Citation Text:
Theme Issue on Medical Error. BMJ. 2000 Mar 18;320(7237):725-814.
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psnet.ahrq.gov/node/33579/psn-pdf
September 15, 2024 - outpatient surgery suite had led to production pressures as well as unexpected changes in the makeup of
the operating … room team. … Computer monitors in the operating room had
been placed in such a way that viewing them forced nurses
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - interventions to improve care processes
Mainly directed at the admission of patients, ward-based care, and the operating … room environment
The intervention with the best evidence is the checklist
14
15
WHO Checklist
The … surgeon)
© WHO, 2009
Before induction of anaesthesia Before skin incision Before patient leaves operating … room
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psnet.ahrq.gov/node/49443/psn-pdf
May 01, 2004 - Privacy Gone Awry
May 1, 2004
Pauker SG, Pauker SP. Privacy Gone Awry. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/privacy-gone-awry
The Case
A 3-year-old child underwent bilateral myringotomies and tube insertion with adenoidectomy.
Preoperatively, she had an upper respiratory infection, but was eating…
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psnet.ahrq.gov/node/44813/psn-pdf
February 15, 2017 - In this prospective trial, operating rooms (ORs) were equipped with remote video
auditing and then cluster-randomized
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psnet.ahrq.gov/issue/systematic-quantitative-assessment-risks-associated-poor-communication-surgical-care
August 11, 2010 - June 1, 2012
Assessing system failures in operating rooms and intensive care units.
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psnet.ahrq.gov/issue/room-hazards-comparison-differences-safety-hazard-recognition-among-various-hospital-based
April 01, 2020 - Study
Room of hazards: a comparison of differences in safety hazard recognition among various hospital-based healthcare professionals and trainees in a simulated patient room.
Citation Text:
Wang M, Banda B, Rodwin BA, et al. Room of hazards: a comparison of differences in safety hazard …
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psnet.ahrq.gov/issue/burden-peri-operative-work-night-perceived-anaesthesiologists-international-survey
May 08, 2024 - September 16, 2009
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Operating Room