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psnet.ahrq.gov/issue/understanding-clinical-implications-resident-involvement-uncommon-operations
October 26, 2022 - September 3, 2008
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Operating Room
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psnet.ahrq.gov/issue/situ-simulated-cardiac-arrest-exercises-detect-system-vulnerabilities
June 27, 2012 - June 27, 2012
Operating room–to-ICU patient handovers: a multidisciplinary human-centered
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psnet.ahrq.gov/issue/effect-sleep-deprivation-after-night-shift-duty-simulated-crisis-management-residents
August 09, 2023 - January 27, 2010
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Operating Room
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psnet.ahrq.gov/issue/patient-handoffs-standardized-and-reliable-measurement-tools-remain-elusive
July 13, 2010 - February 28, 2011
Noise in the operating room—what do we know?
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psnet.ahrq.gov/issue/surgical-skill-predicted-ability-detect-errors
September 02, 2020 - December 17, 2008
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Operating Room
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psnet.ahrq.gov/issue/undermining-and-bullying-surgical-training-review-and-recommendations-association-surgeons
July 25, 2018 - May 26, 2010
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Operating Room
Health
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psnet.ahrq.gov/issue/systematic-review-identify-factors-affect-failure-rescue-and-escalation-care-surgery
September 09, 2015 - February 20, 2013
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Operating Room
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psnet.ahrq.gov/issue/anesthetic-mishaps-breaking-chain-accident-evolution
April 08, 2011 - April 7, 2019
How does patient safety culture in the operating room and post-anesthesia
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psnet.ahrq.gov/issue/closed-loop-communication-interprofessional-emergency-teams-cross-sectional-observation-study
September 24, 2016 - March 15, 2023
Safety culture in the operating room: variability among perioperative
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psnet.ahrq.gov/issue/essential-elements-nurses-have-address-promote-safe-discharge-paediatrics-systematic-review
September 28, 2022 - January 4, 2019
Healthcare personnel attire in non–operating-room settings.
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psnet.ahrq.gov/node/60268/psn-pdf
April 29, 2020 - She was taken to the operating room and underwent an uneventful change of the
ECMO circuit. … Therefore, it took the perfusionist almost 30 minutes to
see the patient after the patient left the operating … room. … room
back to the ICU. … room.12,13
Staff training and education
Guidelines for education are published and updated by the
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_cord-prolapse.docx
May 01, 2017 - simulation can end after definitive plan for patient care is put into place (for example, transition to OR [operating … room]), and no further opportunities for teamwork and communication are apparent. … Partner gets very emotional and starts crying when team suggests movement to the OR [operating room]
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/situ/simulation-cord-prolapse.html
July 01, 2023 - simulation can end after definitive plan for patient care is put into place (for example, transition to OR [operating … room]), and no further opportunities for teamwork and communication are apparent.
… Partner gets very emotional and starts crying when team suggests movement to the OR [operating room]
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psnet.ahrq.gov/node/49791/psn-pdf
April 01, 2017 - to 7.48 per 10,000 blocks.(5) Few studies exist on wrong-site
procedures performed outside of the operating … room (OR). … Incorrect surgical procedures within and outside of the operating
room. … Incorrect surgical procedures within and outside of the operating
room: a follow-up report.
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psnet.ahrq.gov/node/49814/psn-pdf
December 01, 2017 - information, the newly
hired anesthesiologist did not speak up about his unfamiliarity with protocol, and no operating … room (OR)
team member initiated a debrief. … Communication failures in the operating room: an observational
classification of recurrent types and … Perception of safety of surgical practice among operating room
personnel from survey data is associated
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psnet.ahrq.gov/web-mm/secured-not-always-safe
October 01, 2015 - patients is very important to allay fears associated with anesthesia, concern of recalling events from the operating … room, and safety. … room. … OR Peeping
March 1, 2004
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Operating … Room
Physicians
Risk Managers
Anesthesiology
Surgery
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/physician-staff-engagement-slides.pptx
January 01, 2017 - Safety Program for Mechanically Ventilated Patients
6
Perceptions of Teamwork
RN Labor and Delivery Operating … Room Intensive Care Unit Nurse Anesthetist/
Anesthesiologist 48 48 54 59 Physician Labor and Delivery … Operating Room Intensive Care Unit Nurse Anesthetist/
Anesthesiologist 83 88 90 93
% Reporting Adequate … xlsx
image3.png
image1.tif
Sheet1
RN Physician
Labor and Delivery 48 83
Operating … Room 48 88
Intensive Care Unit 54 90
Nurse Anesthetist/
Anesthesiologist 59 93
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-event-reporting_revised.docx
April 01, 2022 - locations/room numbers and staffing ratios):
Location of insertion:
☐ Emergency department ☐ Operating … room ☐ Cardiac catheterization lab ☐ Radiology ☐ Intensive care unit … room, emergency department, physical therapy/occupational therapy, etc.? … kept in a centralized medication area and do not enter the immediate patient treatment area (e.g., operating … room, patient room/cubicle) (Note: If multidose vials enter the immediate patient treatment area they
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psnet.ahrq.gov/web-mm/time-death
January 03, 2017 - communication errors as a root cause in more than 60% of events.( 12 ) Observation of teams in the operating … room suggest that as many as 30% of communications are substandard or contain a particular type of communication … Human factors in the operating room: Interpersonal determinants of safety, efficiency, and morale. … Communication failures in the operating room: an observational classification of recurrent types and … room–to-ICU patient handovers: a multidisciplinary human-centered design approach.
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psnet.ahrq.gov/node/72587/psn-pdf
December 23, 2020 - pediatric anesthesiologist arrived in the PICU to assess the patient and assist with transport to
the operating … room (OR). … their care by an anesthesiologist.8 Locations of these events included the preoperative holding
area, operating … room, post-anesthesia care unit, and any preoperative or postoperative transfer to or from
the ICU. … Room.