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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/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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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
April 04, 2008 - A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care
A Visual Computer Interface Concept for Making
Error Reporting Useful at the Point of Care
Ranjit Singh, MA, MB, BChir (Cantab.), MBA; Wilson Pace, MD; Ashok Singh, MA, MB,
BChir (Cantab); Chester Fox, MD; Gurdev Singh, MSc…
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/cauti-surveillance/review-form.html
March 01, 2017 - Appendix K. CAUTI Case Review Form
AHRQ Safety Program for Long-Term Care: HAIs/CAUTI
Purpose
The CAUTI Case Review Form is a performance improvement look-back tool that assists long-term care (LTC) facilities with identifying possible resident care issues that might have contributed to a cathet…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
April 01, 2025 - MRSA infection
A MRSA surgical site infection (SSI)
Incomplete cleaning of high-touch surfaces in the operating … room, pre-op, and post recovery areas as evidenced by residual fluorescent material during EVS assessment
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_fullcolor.pdf
May 01, 2017 - management and electronic fetal heart rate
interpretation, emergent cesarean section transfer to the
operating … room, and a mock code to simulate a cardiac or
pulmonary arrest situation in an obstetric patient. … attended by all key staff from the L&D unit, the intensive-
care unit (ICU), the NICU, anesthesia, and the operating … room. … The
rapid response nurse then alerts the charge nurse in the
operating room.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/perinatal_care_toolkit_lowvision.pdf
May 01, 2017 - management and electronic fetal heart rate
interpretation, emergent cesarean section transfer to the
operating … room, and a mock code to simulate a cardiac or
pulmonary arrest situation in an obstetric patient. … attended by all key staff from the L&D unit, the intensive-
care unit (ICU), the NICU, anesthesia, and the operating … room. … The
rapid response nurse then alerts the charge nurse in the
operating room.
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www.ahrq.gov/hai/cusp/toolkit/content-calls/small-hospitals.html
April 01, 2013 - We do have an operating room. We do have perioperative services. So we do wear a lot of hats. … quality director, but we made sure we had nurses represented from the various areas, including the operating … room.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/125-cusp-science-safety.pptx
April 01, 2025 - Marta returns to the operating room for incision and drainage of a surgical site infection (SSI).
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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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www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
December 01, 2017 - Review a defect in your operating rooms.
Select one defect per month.
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hcup-us.ahrq.gov/reports/methods/MS2021-05-CCR-Methodologies.pdf
December 17, 2021 - X
Skilled Nursing Facility X
Nursing Facility X
Other Long-Term Care X
Operating … Room,
Endoscopy, Prostheses
X
Recovery Room X
Delivery Room & Labor
Room
X
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www.ahrq.gov/hai/cusp/toolkit/content-calls/briefing.html
April 01, 2013 - This is often routine activities such as already seeing other patients, being in the operating room or
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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/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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digital.ahrq.gov/sites/default/files/docs/page/2006Rosati_052411comp.pdf
June 05, 2006 - e-transitions: Improving the Transition to Home Health Care Using an Electronic Communication System Available to Physicians, Discharge Planners, Home Health Nurses and Patients
e-transitions: Improving the Transition to
Home Health Care Using an Electronic
Communication System Available to
Physicians, Discharge…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/sustainability/management/kit.html
June 01, 2017 - includes key performance measures and measures of consistent completion of standard work such as the operating … room huddle.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/navigating-hierarchy-transcript.doc
December 10, 2013 - Paul Tedrick
AHA – Chicago
December 10, 2013
11:00AM CT
Operator:
This is a recording for the Paul Tedrick teleconference with American Hospital Association Chicago, Tuesday, December 10th, 2013, scheduled for 11:00AM Central Time. Ladies and gentlemen, thank you for your patience in holding; we now have our speake…
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www.ahrq.gov/hai/cauti-tools/archived-webinars/navigating-hierarchy-transcript.html
December 01, 2017 - Navigating Hierarchy in the Clinical Setting: Working and Communicating with Others (December 10, 2013)
Webinar Transcript
Paul Tedrick
AHA – Chicago
December 10, 2013
11:00AM CT
Operator: This is a recording for the Paul Tedrick teleconference with American Hospital Association Chicago, Tuesday, Dec…
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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 …