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psnet.ahrq.gov/node/33611/psn-pdf
July 01, 2005 - They
would be shocked that surgeries are being performed and intensive care is routinely delivered by
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psnet.ahrq.gov/node/33700/psn-pdf
October 01, 2010 - What we found is—I think it's no different than why we see that wrong-site surgeries haven't gone
down
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psnet.ahrq.gov/node/33658/psn-pdf
October 01, 2007 - course, is incredibly important because many of the harms are relatively rare, and you can do
a lot of surgeries
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psnet.ahrq.gov/node/33639/psn-pdf
September 01, 2006 - That enabled us, for instance,
to learn that 44% of incorrect surgeries were right-left mix-ups, versus
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psnet.ahrq.gov/node/49693/psn-pdf
October 01, 2013 - In
general, transgender persons who have not undergone gender-affirmative surgeries or used hormonal
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psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - SPOTLIGHT CASE
Despite Clues, Failed to Rescue
Citation Text:
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/41355/psn-pdf
April 05, 2013 - Comparative economic analyses of patient safety
improvement strategies in acute care: a systematic
review.
April 5, 2013
Etchells E, Koo M, Daneman N, et al. Comparative economic analyses of patient safety improvement
strategies in acute care: a systematic review. BMJ Qual Saf. 2012;21(6):448-56. doi:10.1136/bmjqs…
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psnet.ahrq.gov/node/37874/psn-pdf
April 18, 2011 - Interprofessional handover and patient safety in
anaesthesia: observational study of handovers in the
recovery room.
April 18, 2011
Smith AF, Pope C, Goodwin D, et al. Interprofessional handover and patient safety in anaesthesia:
observational study of handovers in the recovery room. Br J Anaesth. 2008;101(3):332-…
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psnet.ahrq.gov/node/73109/psn-pdf
April 07, 2021 - Common general surgical never events: analysis of NHS
England never event data.
April 7, 2021
Omar I, Singhal R, Wilson M, et al. Common general surgical never events: analysis of NHS England never
event data. Int J Qual Health Care. 2021;33(1):mzab045. doi:10.1093/intqhc/mzab045.
https://psnet.ahrq.gov/issue/comm…
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psnet.ahrq.gov/node/845631/psn-pdf
March 08, 2023 - Evaluation of policies limiting opioid exposure on opioid
prescribing and patient pain in opioid-naive patients
undergoing elective surgery in a large American health
system.
March 8, 2023
Rennert L, Howard KA, Walker KB, et al. Evaluation of policies limiting opioid exposure on opioid
prescribing and patient pai…
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psnet.ahrq.gov/node/49389/psn-pdf
February 01, 2003 - Procedural Mishap: Learning Curve?
February 1, 2003
Gibbs VC, Leape L. Procedural Mishap: Learning Curve? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
The Case
A 28-year-old multiparous obese female presented for laparoscopic tubal ligation. The patient had
undesired fert…
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psnet.ahrq.gov/node/49814/psn-pdf
December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation
Mishap
December 1, 2017
Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
The Case
A 63-year-old man with a history of coronary…
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psnet.ahrq.gov/issue/integration-formalized-handoff-system-surgical-curriculum-resident-perspectives-and-early
May 25, 2016 - Study
Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results.
Citation Text:
Telem DA. Integration of a Formalized Handoff System Into the Surgical Curriculum. Archives of Surgery. 2011;146(1). doi:10.1001/archsurg.2010.294.
Cop…
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psnet.ahrq.gov/issue/towards-model-surgeons-leadership-operating-room
July 01, 2020 - Review
Towards a model of surgeons' leadership in the operating room.
Citation Text:
Parker SH, Yule S, Flin R, et al. Towards a model of surgeons' leadership in the operating room. BMJ Qual Saf. 2011;20(7):570-9. doi:10.1136/bmjqs.2010.040295.
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Format:
DOI G…
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psnet.ahrq.gov/issue/tracking-intraoperative-complications
April 30, 2014 - Study
Tracking intraoperative complications.
Citation Text:
Platz J, Hyman N. Tracking intraoperative complications. J Am Coll Surg. 2012;215(4):519-23. doi:10.1016/j.jamcollsurg.2012.06.001.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/issue/surgical-fires-clear-and-present-danger
May 16, 2018 - Review
Surgical fires, a clear and present danger.
Citation Text:
Yardley IE, Donaldson LJ. Surgical fires, a clear and present danger. Surgeon. 2010;8(2):87-92. doi:10.1016/j.surge.2010.01.005.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote …
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psnet.ahrq.gov/issue/enhancing-surgical-team-communication-sops-and-teamstepps-action
August 01, 2012 - Meeting/Conference Proceedings
Enhancing Surgical Team Communication: SOPS and TeamSTEPPS in Action.
Citation Text:
Enhancing Surgical Team Communication: SOPS and TeamSTEPPS in Action. Agency for Healthcare Research and Quality. July 25, 2024.
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…
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psnet.ahrq.gov/issue/tqip-mortality-reporting-system-case-reports
March 23, 2022 - Special or Theme Issue
TQIP Mortality Reporting System Case Reports.
Citation Text:
TQIP Mortality Reporting System Case Reports. ACS TQIP Mortality Reporting System Writing Group. J Trauma Acute Care Surg. 2023.
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Pri…
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psnet.ahrq.gov/issue/safety-and-quality-perioperative-anesthesia-care
June 15, 2011 - Special or Theme Issue
Safety and Quality in Perioperative Anesthesia Care.
Citation Text:
Safety and Quality in Perioperative Anesthesia Care. Preckel B, ed. Best Pract Res Clin Anaesthesiol. 2021;35(1):1-154.
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…
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psnet.ahrq.gov/issue/skin-deep-diagnosis-affective-bias-and-zebra-retreat-complicating-diagnosis-systemic
July 29, 2020 - Commentary
Skin-deep diagnosis: affective bias and zebra retreat complicating the diagnosis of systemic sclerosis.
Citation Text:
Miller CS. Skin-deep diagnosis: affective bias and zebra retreat complicating the diagnosis of systemic sclerosis. Am J Med Sci. 2013;345(1):53-6. doi:10.1…