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psnet.ahrq.gov/node/38192/psn-pdf
November 05, 2008 - Evaluation of critical incidents in general surgery.
November 5, 2008
Zingg U, Zala-Mezoe E, Kuenzle B, et al. Evaluation of critical incidents in general surgery. Br J Surg.
2008;95(11):1420-5. doi:10.1002/bjs.6296.
https://psnet.ahrq.gov/issue/evaluation-critical-incidents-general-surgery
This study developed an…
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psnet.ahrq.gov/web-mm/listen-family
April 15, 2015 - Listen to the Family
Citation Text:
Campbell D. Listen to the Family. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/or
August 22, 2013 - On O.R. Off?
Citation Text:
Leonard M. On O.R. Off?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Do…
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psnet.ahrq.gov/node/49620/psn-pdf
February 01, 2011 - Silent Pain in the Neck
February 1, 2011
Bittner EA. Silent Pain in the Neck. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/silent-pain-neck
The Case
A 60-year-old man with no significant past medical history underwent an elective anterior cervical
discectomy for persistent right arm weakness due to cervi…
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psnet.ahrq.gov/node/41468/psn-pdf
October 19, 2012 - Surgeons don't know what they don't know about the safe
use of energy in surgery.
October 19, 2012
Feldman LS, Fuchshuber PR, Jones DB, et al. Surgeons don't know what they don't know about the safe
use of energy in surgery. Surg Endosc. 2012;26(10):2735-9.
https://psnet.ahrq.gov/issue/surgeons-dont-know-what-they…
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psnet.ahrq.gov/node/39285/psn-pdf
February 10, 2010 - Factors compromising safety in surgery: stressful events
in the operating room.
February 10, 2010
Arora S, Hull L, Sevdalis N, et al. Factors compromising safety in surgery: stressful events in the operating
room. Am J Surg. 2010;199(1):60-5. doi:10.1016/j.amjsurg.2009.07.036.
https://psnet.ahrq.gov/issue/factors-…
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psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn
February 10, 2010 - Residual Anesthesia: Tepid Burn
Citation Text:
Kurrek MM, Twersky RS. Residual Anesthesia: Tepid Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/41956/psn-pdf
December 21, 2014 - Integrating human factors research and surgery: a review.
December 21, 2014
Shouhed D, Gewertz BL, Wiegmann D, et al. Integrating human factors research and surgery: a review.
Arch Surg. 2012;147(12):1141-1146. doi:10.1001/jamasurg.2013.596.
https://psnet.ahrq.gov/issue/integrating-human-factors-research-and-surger…
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psnet.ahrq.gov/node/41931/psn-pdf
December 19, 2012 - Preventing wrong-site surgery in Minnesota: a 5-year
journey.
December 19, 2012
Rydrych D, Apold J, Harder K. Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34.
https://psnet.ahrq.gov/issue/preventing-wrong-site-surgery-minnesota-5-year-journey
Discussing a 5-year effort to report, analyze, and red…
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psnet.ahrq.gov/node/73380/psn-pdf
June 09, 2021 - Wrong Site Surgery–Wrong Tooth Extraction.
June 9, 2021
Farnborough, UK: Healthcare Safety Investigation Branch; April 2021.
https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-tooth-extraction
Wrong-site surgery in dentistry is a frequent and persistent never event. This report examines a case of
pediatric wron…
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psnet.ahrq.gov/node/44110/psn-pdf
May 13, 2015 - Simulation in Anaesthesia and Surgery.
May 13, 2015
Hahnenkamp K, Breuer G, eds. Best Pract Res Clin Anaesthesiol. 2015;29(1):1-96.
https://psnet.ahrq.gov/issue/simulation-anaesthesia-and-surgery
In the last decade, simulation has emerged as an educational strategy for teaching clinical skills. Articles in
this sp…
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psnet.ahrq.gov/node/40582/psn-pdf
July 06, 2011 - Patient safety climate among orthopaedic surgery
residents.
July 6, 2011
Kadzielski J, McCormick F, Zurakowski D, et al. Patient safety climate among orthopaedic surgery
residents. J Bone Joint Surg Am. 2011;93(11):e62. doi:10.2106/JBJS.J.01478.
https://psnet.ahrq.gov/issue/patient-safety-climate-among-orthopaedic…
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psnet.ahrq.gov/node/43941/psn-pdf
February 25, 2015 - How to make surgery safer.
February 25, 2015
https://psnet.ahrq.gov/issue/how-make-surgery-safer
This newspaper article reports on various ways hospitals are working to make surgical care safer and
reduce readmissions due to surgical complications, including checklists, teamwork training courses for
surgeons, preo…
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psnet.ahrq.gov/node/41266/psn-pdf
January 03, 2017 - Surfacing safety hazards using standardized operating
room briefings and debriefings at a large regional medical
center.
January 3, 2017
Bandari J, Schumacher K, Simon M, et al. Surfacing safety hazards using standardized operating room
briefings and debriefings at a large regional medical center. Jt Comm J Qual P…
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psnet.ahrq.gov/issue/surgical-patient-safety-essential-information-surgeons-todays-environment
October 15, 2018 - Book/Report
Surgical Patient Safety Essential Information for Surgeons in Today's Environment.
Citation Text:
Surgical Patient Safety Essential Information for Surgeons in Today's Environment. Manuel BM, Nora PF, eds. Chicago, IL: American College of Surgeons; 2004. ISBN 978188069616…
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psnet.ahrq.gov/issue/parkland-knee-surgery-done-doctor-training-leads-amputation-questions
August 11, 2010 - Newspaper/Magazine Article
Parkland knee surgery done by doctor in training leads to amputation, questions.
Citation Text:
Parkland knee surgery done by doctor in training leads to amputation, questions. Egerton B. Dallas Morning News. November 14, 2010;A01.
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psnet.ahrq.gov/issue/ambulatory-surgery-facilities-comprehensive-review-medication-error-reports-pennsylvania
April 17, 2017 - Newspaper/Magazine Article
Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania.
Citation Text:
Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania.
Grissinger M, Dabliz R. Pa Patient S…
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psnet.ahrq.gov/issue/assessing-distractors-and-teamwork-during-surgery-developing-event-based-method-direct
February 19, 2020 - Study
Assessing distractors and teamwork during surgery: developing an event-based method for direct observation.
Citation Text:
Seelandt JC, Tschan F, Keller S, et al. Assessing distractors and teamwork during surgery: developing an event-based method for direct observation. BMJ Qual Sa…
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psnet.ahrq.gov/issue/implementing-standardized-safe-surgery-program-reduces-serious-reportable-events
October 30, 2024 - Study
Implementing a standardized safe surgery program reduces serious reportable events.
Citation Text:
Loftus T, Dahl D, OHare B, et al. Implementing a standardized safe surgery program reduces serious reportable events. J Am Coll Surg. 2015;220(1):12-17.e3. doi:10.1016/j.jamcollsurg.2…
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psnet.ahrq.gov/issue/smartphones-let-surgeons-know-whatsapp-analysis-communication-emergency-surgical-teams
April 06, 2015 - Study
Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams.
Citation Text:
Johnston MJ, King D, Arora S, et al. Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. Am J Surg. 2015;209(1):45-51. doi:…