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Showing results for "operating room".

  1. An interview with Peter Pronovost | PSNet

    psnet.ahrq.gov/issue/interview-peter-pronovost
    July 01, 2017 - November 30, 2011 Assessing system failures in operating rooms and intensive care units

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867497/psn-pdf
    February 26, 2025 - of error propagation can be informative in understanding the complexity of RSI causation.1 In the operating … room (OR) or procedural area, each slice of Swiss cheese represents a group of practitioners or entities

  3. The husband's story: from tragedy to learning and action. | PSNet

    psnet.ahrq.gov/issue/husbands-story-tragedy-learning-and-action
    February 02, 2022 - Commentary The husband's story: from tragedy to learning and action. Citation Text: Bromiley M. The husband's story: from tragedy to learning and action. BMJ Qual Saf. 2015;24(7):425-427. doi:10.1136/bmjqs-2015-004129. Copy Citation Format: DOI Google Scholar PubMed BibTeX …

  4. A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety. | PSNet

    psnet.ahrq.gov/issue/qualitative-study-systemic-influences-paramedic-decision-making-care-transitions-and-patient
    January 08, 2014 - Study A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety. Citation Text: O'Hara R, Johnson M, Siriwardena N, et al. A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety. J He…

  5. Iatrogenic events in neonates: beneficial effects of prevention strategies and continuous monitoring. | PSNet

    psnet.ahrq.gov/issue/iatrogenic-events-neonates-beneficial-effects-prevention-strategies-and-continuous-monitoring
    February 20, 2008 - Implementation of barcode medication administration (BMCA) technology on infusion pumps in the operating … rooms.

  6. Missed Appendicitis | PSNet

    psnet.ahrq.gov/web-mm/missed-appendicitis
    March 13, 2013 - The patient was seen by general surgery and it was decided not to take her to the operating room immediately … The patient went to the operating room the next day for lysis of adhesions and appendectomy.

  7. Say It Again | PSNet

    psnet.ahrq.gov/web-mm/say-it-again
    January 31, 2020 - Communication failures in the operating room: an observational classification of recurrent types and … December 21, 2014 Incorrect surgical procedures within and outside of the operating room

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49856/psn-pdf
    March 01, 2019 - The procedure was initially thought to be uncomplicated, and the patient was extubated in the operating … room. … The patient was taken back to the operating room and found to have an expanding neck hematoma, which

  9. Clinical Areas | PSNet

    psnet.ahrq.gov/clinical-areas
    March 24, 2025 - Commentary Analyzing and mitigating the risks of patient harm during operating … room to intensive care unit patient handoffs. … This article describes the use of a risk management approach to improve handoffs from the operating room

  10. Turn the Other Cheek | PSNet

    psnet.ahrq.gov/web-mm/turn-other-cheek
    October 26, 2010 - October 4, 2011 WebM&M Cases Good Catch in the Operating … Room May 1, 2019 WebM&M Cases Order Interrupted … 2004 View More See More About The Topic Outpatient Surgery Operating … Room Health Care Providers Quality and Safety Professionals Dermatology View More

  11. Collegiality vs. Competence | PSNet

    psnet.ahrq.gov/web-mm/collegiality-vs-competence
    August 28, 2024 - The Case A 91-year-old man with coronary artery disease was taken to the operating room (OR) for semi-elective … OR Peeping March 1, 2004 View More See More About The Topic Operating … Room Physicians Facility and Group Administrators Risk Managers Policy Makers View

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33821/psn-pdf
    December 01, 2016 - recording or "black box" systems in commercial aircraft, which have recently been experimented with in operating … rooms.(8) These approaches are complex and challenging to implement effectively. … aviation black box principle in pediatric cardiac surgery: tracking all failures in the pediatric cardiac operating … room.

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33832/psn-pdf
    April 01, 2017 - In Conversation With… Kathleen Sutcliffe, MN, PhD April 1, 2017 In Conversation With… Kathleen Sutcliffe, MN, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-kathleen-sutcliffe-mn-phd Editor's note: Professor Sutcliffe is a Bloomberg Distinguished Professor of Business and Medicine at …

  14. Lessons learned from medical malpractice claims involving critical care nurses. | PSNet

    psnet.ahrq.gov/issue/lessons-learned-medical-malpractice-claims-involving-critical-care-nurses
    July 15, 2020 - common diagnosis in claims involving ICU nurses and compared to nurses in emergency departments and operating … rooms, ICU nurses were likely to have a malpractice claim alleging failure to monitor.

  15. Continuing Education | PSNet

    psnet.ahrq.gov/continuing-education
    February 26, 2025 - Departments (44) Intensive Care Units (37) Labor and Delivery (6) Operating … Room (28) Specialty Hospitals (2) Long-Term Care (5) … The surgical team had difficulty controlling bleeding and the patient left the operating room (OR) with

  16. Coming Undone: Failure of Closure Device | PSNet

    psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
    April 01, 2006 - He was taken to the operating room, and it was discovered the angio-seal closure device had failed and … 2006 View More See More About The Topic Outpatient Surgery Operating … Room Physicians Cardiology Cardiothoracic Surgery View More

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37255/psn-pdf
    December 19, 2011 - Communicating in the "gray zone": perceptions about emergency physician-hospitalist handoffs and patient safety. December 19, 2011 Apker J, Mallak LA, Gibson SC. Communicating in the "gray zone": perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007;14(10):884-94. htt…

  18. Occupational Health and Organizational Culture within a Healthcare Setting: Challenges, Complexities, and Dynamics. | PSNet

    psnet.ahrq.gov/issue/occupational-health-and-organizational-culture-within-healthcare-setting-challenges
    December 08, 2021 - and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United States operating … rooms.

  19. Failure mode and effects analysis application to critical care medicine. | PSNet

    psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-application-critical-care-medicine
    June 10, 2013 - December 21, 2011 Assessing system failures in operating rooms and intensive care units

  20. Momentary interruptions can derail the train of thought. | PSNet

    psnet.ahrq.gov/issue/momentary-interruptions-can-derail-train-thought
    May 18, 2022 - Identification and interference of intraoperative distractions and interruptions in operating … rooms.
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