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psnet.ahrq.gov/node/866579/psn-pdf
August 28, 2024 - Before discharge, the surgeon instructed her to return in 10 days for suture removal. … The surgeon also
told the patient not to soak her hand in water, which would reduce the risk of infection … The MA did not document each call but reportedly discussed each
call with the surgeon. … One day later, the patient
called and asked to see the surgeon, but she was denied because the MA said … At that appointment, the surgeon
recommended immediate surgery to treat the infection.
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psnet.ahrq.gov/web-mm/inadvertent-castration
October 27, 2010 - In the recovery room, the surgeon discussed the changes to the planned procedure with the patient's wife … , who informed the surgeon that the patient's right testicle had been removed after a traumatic injury … Likewise, it would be helpful to have information about the extent to which the operating surgeon was … Wrong-site Surgery and Other Cognitive Errors
In this case, the surgeon almost certainly never considered … In this anachronistic model, the non-surgeon physician, resident, nurse, and technician team members
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psnet.ahrq.gov/node/837347/psn-pdf
June 08, 2022 - Surgeon General’s Advisory on Building a Thriving Health Workforce. … Washington DC:
Office of the Surgeon General; May 2022.
-
www.ahrq.gov/research/findings/final-reports/ssi/ssiexh62-64.html
April 01, 2018 - Assessing Surgeon Acceptance of Risk Adjustment Models
Chapter 5. Project Expansion
Chapter 6. … Surgeon Focus Group Guide
Appendix O. Nursing Focus Group Guides
Appendix P. … Surgeon Focus Group Content Analysis
Appendix R. Infection Prevention Support Tool
Appendix S.
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh23.html
April 01, 2018 - Assessing Surgeon Acceptance of Risk Adjustment Models
Chapter 5. Project Expansion
Chapter 6. … Surgeon Focus Group Guide
Appendix O. Nursing Focus Group Guides
Appendix P. … Surgeon Focus Group Content Analysis
Appendix R. Infection Prevention Support Tool
Appendix S.
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh56-58.html
April 01, 2018 - Assessing Surgeon Acceptance of Risk Adjustment Models
Chapter 5. Project Expansion
Chapter 6. … Surgeon Focus Group Guide
Appendix O. Nursing Focus Group Guides
Appendix P. … Surgeon Focus Group Content Analysis
Appendix R. Infection Prevention Support Tool
Appendix S.
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psnet.ahrq.gov/glossary/swiss-cheese-model
September 13, 2021 - conventions for identifying sidedness on radiology tests, a protocol for signing the correct site when the surgeon … The surgeon may meet the patient for the first time in the operating room. … A hurried x-ray technologist might mislabel a film (or simply hang it backwards and a hurried surgeon
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www.ahrq.gov/hai/tools/surgery/modules/implementation/audit-briefing-fac-notes.html
December 01, 2017 - The best way to build engagement and surgeon buy-in is to add value for them. … Ask:
Do you want to observe five briefings from each surgeon? … As an example, we evaluated a few cases for each surgeon. … Regardless of surgeon, each common procedure pulled from this core list. … Then each individual surgeon could add specialty items if requested.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_audit_briefing_facnotes.docx
December 01, 2017 - The best way to build engagement and surgeon buy-in is to add value for them. … ASK:
Do you want to observe five briefings from each surgeon? … As an example, we evaluated a few cases for each surgeon. … Regardless of surgeon, each common procedure pulled from this core list. … Then each individual surgeon could add specialty items if requested.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.33_slideshow.ppt
October 01, 2003 - As the trainee prepared to make an incision on the left side of the vulva, the attending surgeon stopped … by senior staff members
Responses differed by profession (% “yes”):
Airline pilot response: 97%
Surgeon … The surgeon denied that any error had been made; he insisted that the original biopsies had been mislabeled … The surgeon did not inform the patient of the error. … .): Wrong Side Surgery
When the patient returned for routine follow-up, the surgeon performed a vulvar
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psnet.ahrq.gov/node/74251/psn-pdf
January 26, 2022 - health records but
without seeing the patient, who was in another hospital, the anesthetist asked the surgeon … After induction of general anesthesia, the assistant surgeon tried 10 times to cannulate either
subclavian … Unfortunately, the surgeon had damaged an intercostal artery when he inserted the chest tube emergently … Additionally, in this case, the surgeon damaged an intercostal artery while inserting the chest tube … A
preoperative discussion between the attending surgeon and the trainee regarding anticipated risks
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psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - The day following the surgery, the pathologist contacted the surgeon to report no evidence of cancer. … The surgeon then reviewed the initial CT scan and realized his mistake. … Once the surgeon decided he did not need the imaging to proceed with surgical treatment, the proverbial … Either way, the surgeon would have been given the opportunity to review the imaging and identify the … The surgeon moves down one level and completes the procedure appropriately. Table 2.
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ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/mincer.html
August 01, 2017 - Presence of SDM Elements in Surgeon-Patient Decision-making Before and After Training
Figure 3. … Surgeon Barriers and Solutions
Subspecialty Buy-In. … Meetings were held to engage orthopedic surgeon subspecialty groups. … Surgeon Training. Surgeon training presented a series of implementation barriers. … This included trainer observation (“scorecard”) plus surgeon self-assessment.
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psnet.ahrq.gov/node/852805/psn-pdf
August 23, 2023 - This news feature reports
on systemic flaws that enabled a vascular surgeon with questionable business … unstoppable-doctor-has-been-investigated-every-level-government-how-he-still-practicing
https://psnet.ahrq.gov/issue/surgeon-so-bad-it-was-criminal
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh29-31.html
April 01, 2018 - Assessing Surgeon Acceptance of Risk Adjustment Models
Chapter 5. Project Expansion
Chapter 6. … Surgeon Focus Group Guide
Appendix O. Nursing Focus Group Guides
Appendix P. … Surgeon Focus Group Content Analysis
Appendix R. Infection Prevention Support Tool
Appendix S.
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psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
August 05, 2009 - Upon examination of the knee under anesthesia and with visualization from the arthroscope, the surgeon … After the surgery, the surgeon briefed the patient in the post-anesthesia care unit (PACU) on his findings … When the husband picked up the patient, the written discharge instructions from the surgeon were generic … The confusion was never discovered at two subsequent postop visits, in part because the surgeon never … When she experienced significant pain, she called the surgeon who then chastised her for not following
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh8-10.html
April 01, 2018 - Assessing Surgeon Acceptance of Risk Adjustment Models
Chapter 5. Project Expansion
Chapter 6. … Surgeon Focus Group Guide
Appendix O. Nursing Focus Group Guides
Appendix P. … Surgeon Focus Group Content Analysis
Appendix R. Infection Prevention Support Tool
Appendix S.
-
psnet.ahrq.gov/node/50925/psn-pdf
February 19, 2020 - This analysis discusses a criminal case involving one surgeon in the National Health
Service. … report-independent-inquiry-issues-raised-paterson
https://psnet.ahrq.gov/issue/report-morecambe-bay-investigation
https://psnet.ahrq.gov/issue/surgeon-so-bad-it-was-criminal
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psnet.ahrq.gov/node/47473/psn-pdf
December 05, 2018 - who experienced
complications resulting from care, the negative impact on her relationship with her surgeon … , and how she
felt when her surgeon expressed empathy.
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pcmh.ahrq.gov/cahps/surveys-guidance/surgical/index.html
February 01, 2018 - questions ask patients to report on their experiences with office staff during visits and to rate the surgeon … following measures of patient experience:
Information to help you prepare for surgery
How well surgeon … Surgeon's attentiveness on day of surgery
Information to help you recover from surgery
How well surgeon … after surgery
Helpful, courteous, and respectful staff at surgeon's office
Patients' rating of the surgeon