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psnet.ahrq.gov/node/73103/psn-pdf
March 31, 2021 - In the operating room, a
necrotizing infection that tracked from a perirectal horseshoe abscess, through … evaluate perianal pain
and tenderness in an acutely ill patient with examination under anesthesia in the operating … room.
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psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - were there communication gaps or problems with order transcription between the frequent trips to the operating … room and periods when the patient was NPO? … WebM&M Cases
To Dilute or Not Dilute: Drug Errors and Consequences in the Operating … Room
October 27, 2021
WebM&M Cases
When Looks
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psnet.ahrq.gov/node/49855/psn-pdf
March 01, 2019 - propagation of errors.(10,11)
Checklists are associated with improved communication and teamwork in operating … room (12) and
interventional radiology procedures.(13,14) Checklists have been shown to decrease interventional … Do safety checklists improve teamwork and
communication in the operating room?
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - in multiple different clinical settings, for tasks such as identifying correct surgical sites in the operating … room and reducing infections associated with central lines placed in hospitalized patients. 7 However … View More
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Outpatient Surgery
Hospitals
Operating … Room
Health Care Providers
Allied Health Professionals
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psnet.ahrq.gov/node/49628/psn-pdf
June 01, 2011 - The highest risk of
return to the operating room to control hemorrhage occurs one week postoperatively
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psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
January 01, 2022 - • The patient was subsequently taken to the operating room for
exploration and debridement of her … patient
with traumatic injuries was effectively managed both
acutely in the ED and definitively in the operating … room.
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psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - Following an RCA of this event, the operating room (OR) manager was instructed to evaluate all
OR supplies
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psnet.ahrq.gov/node/33578/psn-pdf
September 15, 2024 - to the redesign of anesthesia equipment, significantly reducing the risk of injury
or death in the operating … room.
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psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior
September 15, 2024 - dissatisfaction and likelihood of leaving the nursing profession , and has been linked to adverse events in the operating … room .
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psnet.ahrq.gov/issue/hospitals-scramble-front-lines-drug-shortages
November 29, 2016 - Newspaper/Magazine Article
Hospitals scramble on the front lines of drug shortages.
Citation Text:
Hospitals scramble on the front lines of drug shortages. Sun LH. Washington Post. April 10, 2012.
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psnet.ahrq.gov/issue/washington-hospital-center-safety-program-seeks-catch-near-misses
November 29, 2016 - Newspaper/Magazine Article
Washington Hospital Center safety program seeks to catch 'near-misses.'
Citation Text:
Washington Hospital Center safety program seeks to catch 'near-misses.' Sun LH.
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psnet.ahrq.gov/issue/are-new-safety-paradigms-only-about-safety-and-sufficient-ensure-it-overview-and-critical
October 26, 2022 - Commentary
Are the new safety paradigms (only) about safety and sufficient to ensure it? An overview and critical commentary.
Citation Text:
Karanikas N, Zerguine H. Are the new safety paradigms (only) about safety and sufficient to ensure it? An overview and critical commentary. Safety …
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psnet.ahrq.gov/node/49687/psn-pdf
August 21, 2013 - Improvements have been directed at the admission of patients, ward-based care,
and the operating room
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psnet.ahrq.gov/web-mm/dropped-lung
February 06, 2012 - December 7, 2011
WebM&M Cases
Good Catch in the Operating … Room
May 1, 2019
WebM&M Cases
Turn the Other
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psnet.ahrq.gov/web-mm/urine-tough-position
January 01, 2009 - May 8, 2017
A prospective study of patient safety in the operating room.
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psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
September 27, 2023 - elbow wounds—or at least to appreciate that more thorough evaluation of the wound was required in the operating … room—was the most obvious error in this case, the decision to close the wounds with sutures comes as … Have a low threshold for surgical exploration of a wound in an operating room if there is suspicion of
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - For example, the RIC has led to changes in patient positioning and equipment in the operating room that
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psnet.ahrq.gov/node/33630/psn-pdf
March 01, 2006 - Procedure-based units such as the operating room or the GI suite are easily compared to aviation.
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psnet.ahrq.gov/node/49724/psn-pdf
January 01, 2015 - He was sent urgently back into the operating room in order to fix the perforation, and
postoperatively
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psnet.ahrq.gov/node/33642/psn-pdf
November 01, 2006 - In the operating room, where a lot of
these issues come up, a steady background noise might actually