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psnet.ahrq.gov/issue/inadequate-preoperative-team-briefings-lead-more-intraoperative-adverse-events
June 07, 2023 - Study
Inadequate preoperative team briefings lead to more intraoperative adverse events.
Citation Text:
Phadnis J, Templeton-Ward O. Inadequate Preoperative Team Briefings Lead to More Intraoperative Adverse Events. J Patient Saf. 2018;14(2):82-86. doi:10.1097/PTS.0000000000000181.
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psnet.ahrq.gov/issue/preventing-wrong-site-procedure-and-patient-events-using-common-cause-analysis
October 03, 2017 - Study
Preventing wrong site, procedure, and patient events using a common cause analysis.
Citation Text:
Mallett R, Conroy M, Saslaw LZ, et al. Preventing wrong site, procedure, and patient events using a common cause analysis. Am J Med Qual. 2012;27(1):21-9. doi:10.1177/10628606114120…
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psnet.ahrq.gov/issue/association-between-surgeon-stress-and-major-surgical-complications
November 29, 2023 - Study
Association between surgeon stress and major surgical complications.
Citation Text:
Awtry J, Skinner S, Polazzi S, et al. Association between surgeon stress and major surgical complications. JAMA Surg. 2025;160(3):332-340. doi:10.1001/jamasurg.2024.6072.
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psnet.ahrq.gov/node/38680/psn-pdf
August 18, 2010 - Improving safety in the operating room: a systematic
literature review of retained surgical sponges.
August 18, 2010
Wan W, Le T, Riskin L, et al. Improving safety in the operating room: a systematic literature review of
retained surgical sponges. Curr Opin Anaesthesiol. 2009;22(2):207-14.
doi:10.1097/ACO.0b013e32…
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psnet.ahrq.gov/node/48188/psn-pdf
August 14, 2019 - Analysis of human performance deficiencies associated
with surgical adverse events.
August 14, 2019
Suliburk JW, Buck QM, Pirko CJ, et al. Analysis of Human Performance Deficiencies Associated With
Surgical Adverse Events. JAMA Netw Open. 2019;2(7):e198067.
doi:10.1001/jamanetworkopen.2019.8067.
https://psnet.ahr…
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psnet.ahrq.gov/node/39550/psn-pdf
July 05, 2013 - A novel method for reproducibly measuring the effects of
interventions to improve emotional climate, indices of
team skills and communication, and threat to patient
outcome in a high-volume thoracic surgery center.
July 5, 2013
Nurok M, Lipsitz S, Satwicz P, et al. A novel method for reproducibly measuring the eff…
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psnet.ahrq.gov/node/43045/psn-pdf
August 02, 2015 - A multistep approach to improving biopsy site
identification in dermatology: physician, staff, and patient
roles based on a Delphi consensus.
August 2, 2015
Alam M, Lee A, Ibrahimi OA, et al. A multistep approach to improving biopsy site identification in
dermatology: physician, staff, and patient roles based on a…
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psnet.ahrq.gov/node/837701/psn-pdf
July 20, 2022 - Pediatric surgical errors: a systematic scoping review.
July 20, 2022
Marsh KM, Fleming MA, Turrentine FE, et al. Pediatric surgical errors: a systematic scoping review. J
Pediatr Surg. 2022;57(4):616-621. doi:10.1016/j.jpedsurg.2021.07.019.
https://psnet.ahrq.gov/issue/pediatric-surgical-errors-systematic-scoping-…
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psnet.ahrq.gov/node/866205/psn-pdf
July 10, 2024 - Hemorrhagic Shock after Elective Spine Surgery: Failure
to Rescue after Limited Response to Nursing Concerns.
July 10, 2024
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response
to Nursing Concerns. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hemorrhagic-sh…
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psnet.ahrq.gov/web-mm/empty-handoff
August 01, 2017 - Empty Handoff
Citation Text:
Goldman A, Catchpole K. Empty Handoff. 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/49606/psn-pdf
August 01, 2010 - Weighing In on Surgical Safety
August 1, 2010
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/weighing-surgical-safety
Case Objectives
Identify the comorbidites associated with obesity that place patients at higher risk for surgical
complications.
Un…
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psnet.ahrq.gov/node/43636/psn-pdf
November 26, 2014 - Application of the WHO surgical safety checklist outside
the operating theatre: medicine can learn from surgery.
November 26, 2014
Braham DL, Richardson AL, Malik IS. Application of the WHO surgical safety checklist outside the
operating theatre: medicine can learn from surgery. Clin Med. 2014;14(5):468-474.
doi:1…
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psnet.ahrq.gov/node/46497/psn-pdf
January 01, 2021 - Identifying risks and opportunities in outpatient surgical
patient safety: a qualitative analysis of Veterans Health
Administration staff perceptions.
January 31, 2018
Mull HJ, Rosen AK, Charns MP, et al. Identifying Risks and Opportunities in Outpatient Surgical Patient
Safety: A Qualitative Analysis of Veterans …
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psnet.ahrq.gov/issue/quick-tips-when-getting-prescription
December 24, 2008 - Government Resource
Quick Tips—When Getting A Prescription.
Citation Text:
Quick Tips—When Getting A Prescription. Agency for Healthcare Research and Quality; AHRQ.
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psnet.ahrq.gov/issue/misdiagnosis-more-common-drug-errors-or-wrong-site-surgery
March 13, 2013 - Newspaper/Magazine Article
Misdiagnosis is more common than drug errors or wrong-site surgery.
Citation Text:
Misdiagnosis is more common than drug errors or wrong-site surgery. Boodman SG. Washington Post. May 6, 2013.
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psnet.ahrq.gov/issue/guide-healthcare-quality-how-know-it-when-you-see-it
December 24, 2008 - Book/Report
Guide to Healthcare Quality: How to Know It When You See It.
Citation Text:
Guide to Healthcare Quality: How to Know It When You See It. Rockville, MD: Agency for Healthcare Research and Quality; 2005.
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psnet.ahrq.gov/issue/tomorrows-operating-room-harness-net-rfid
September 09, 2015 - Newspaper/Magazine Article
Tomorrow's operating room to harness Net, RFID.
Citation Text:
Tomorrow's operating room to harness Net, RFID. Olsen S. CNET. October 19, 2005.
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psnet.ahrq.gov/issue/improving-health-care-quality-guide-patients-and-families
December 24, 2008 - Toolkit
Improving Health Care Quality: A Guide for Patients and Families.
Citation Text:
Improving Health Care Quality: A Guide for Patients and Families. Agency for Healthcare Research and Quality (AHRQ)
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psnet.ahrq.gov/issue/national-safety-standards-invasive-procedures-natssips
September 10, 2014 - Organizational Policy/Guidelines
National Safety Standards for Invasive Procedures (NatSSIPs2).
Citation Text:
National Safety Standards for Invasive Procedures (NatSSIPs2). Centre for Perioperative Care. London, UK; January 2023.
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psnet.ahrq.gov/web-mm/over-counter-oversight
March 21, 2009 - Over-the-Counter Oversight
Citation Text:
Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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