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psnet.ahrq.gov/issue/patient-safety-movement-history-and-future-directions
February 21, 2015 - Review
Patient safety movement: history and future directions.
Citation Text:
Lark ME, Kirkpatrick K, Chung KC. Patient Safety Movement: History and Future Directions. J Hand Surg Am. 2018;43(2). doi:10.1016/j.jhsa.2017.11.006.
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psnet.ahrq.gov/issue/safety-stop-valuable-addition-pediatric-universal-protocol
June 21, 2015 - Commentary
Safety stop: a valuable addition to the pediatric universal protocol.
Citation Text:
Caruso TJ, Munshey F, Aldorfer B, et al. Safety Stop: A Valuable Addition to the Pediatric Universal Protocol. Jt Comm J Qual Patient Saf. 2018;44(9):552-556. doi:10.1016/j.jcjq.2018.03.015.
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psnet.ahrq.gov/issue/simulation-based-clinical-rehearsals-method-improving-patient-safety
September 28, 2022 - Commentary
Simulation-based clinical rehearsals as a method for improving patient safety.
Citation Text:
Arnold J, Cashin M, Olutoye OO. Simulation-Based Clinical Rehearsals as a Method for Improving Patient Safety. JAMA Surg. 2018;153(12):1143-1144. doi:10.1001/jamasurg.2018.3526.
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psnet.ahrq.gov/issue/management-adverse-surgical-events-structured-education-module-residents
August 26, 2011 - Study
Management of adverse surgical events: a structured education module for residents.
Citation Text:
Brewster LP, Risucci DA, Joehl RJ, et al. Management of adverse surgical events: a structured education module for residents. Am J Surg. 2005;190(5):687-90.
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psnet.ahrq.gov/issue/chasing-6-sigma-drawing-lessons-cockpit-culture
April 22, 2015 - Commentary
Chasing the 6-sigma: drawing lessons from the cockpit culture.
Citation Text:
Hickey EJ, Halvorsen F, Laussen PC, et al. Chasing the 6-sigma: Drawing lessons from the cockpit culture. J Thorac Cardiovasc Surg. 2017;155(2). doi:10.1016/j.jtcvs.2017.09.097.
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psnet.ahrq.gov/issue/using-change-model-reduce-risk-surgical-site-infection
June 06, 2018 - Commentary
Using a change model to reduce the risk of surgical site infection.
Citation Text:
Burden M. Using a change model to reduce the risk of surgical site infection. Br J Nurs. 2016;25(17):949-955.
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psnet.ahrq.gov/issue/simulated-laparoscopic-operating-room-crisis-approach-enhance-surgical-team-performance
March 28, 2012 - Study
Simulated laparoscopic operating room crisis: an approach to enhance the surgical team performance.
Citation Text:
Powers KA, Rehrig ST, Irias N, et al. Simulated laparoscopic operating room crisis: An approach to enhance the surgical team performance. Surg Endosc. 2008;22(4):885…
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psnet.ahrq.gov/issue/consensus-based-recommendations-standardizing-terminology-and-reporting-adverse-events
December 22, 2018 - Commentary
Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children.
Citation Text:
Bhatt M, Kennedy RM, Osmond MH, et al. Consensus-Based Recommendations for Standardizing Terminol…
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psnet.ahrq.gov/issue/simulation-enhance-patient-safety-why-arent-we-there-yet
June 17, 2015 - Commentary
Simulation to enhance patient safety: why aren't we there yet?
Citation Text:
Aggarwal R, Darzi A. Simulation to enhance patient safety: why aren't we there yet? Chest. 2011;140(4):854-858. doi:10.1378/chest.11-0728.
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psnet.ahrq.gov/issue/eacts-guidelines-use-patient-safety-checklists
October 31, 2012 - Commentary
EACTS guidelines for the use of patient safety checklists.
Citation Text:
Clark SC, Dunning J, Alfieri OR, et al. EACTS guidelines for the use of patient safety checklists. Eur J Cardiothorac Surg. 2012;41(5):993-1004. doi:10.1093/ejcts/ezs009.
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psnet.ahrq.gov/issue/new-paradigm-surgical-procedural-training
December 21, 2014 - Commentary
A new paradigm for surgical procedural training.
Citation Text:
Sachdeva AK, Buyske J, Dunnington GL, et al. A new paradigm for surgical procedural training. Curr Probl Surg. 2011;48(12):854-968. doi:10.1067/j.cpsurg.2011.08.003.
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psnet.ahrq.gov/issue/disruptive-orthopaedic-surgeon-implications-patient-safety-and-malpractice-liability
August 20, 2018 - Commentary
The disruptive orthopaedic surgeon: implications for patient safety and malpractice liability.
Citation Text:
Patel P, Robinson BS, Novicoff WM, et al. The disruptive orthopaedic surgeon: implications for patient safety and malpractice liability. J Bone Joint Surg Am. 2011;…
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psnet.ahrq.gov/issue/six-things-every-plastic-surgeon-needs-know-about-teamwork-training-and-checklists
September 07, 2016 - Image/Poster
Six things every plastic surgeon needs to know about teamwork training and checklists.
Citation Text:
Harden SW. Six things every plastic surgeon needs to know about teamwork training and checklists. Aesthet Surg J. 2013;33(3):443-8. doi:10.1177/1090820X13477417.
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psnet.ahrq.gov/issue/do-micropauses-prevent-surgeons-fatigue-and-loss-accuracy-associated-prolonged-surgery
November 29, 2023 - Study
Do micropauses prevent surgeon's fatigue and loss of accuracy associated with prolonged surgery? An experimental prospective study.
Citation Text:
Dorion D, Darveau S. Do micropauses prevent surgeon's fatigue and loss of accuracy associated with prolonged surgery? An experimental…
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psnet.ahrq.gov/issue/clinical-care-checklists-salvations-or-frustrations
September 01, 2018 - Commentary
Clinical care checklists: salvations or frustrations?
Citation Text:
Jones JW, McCullough LB. Clinical care checklists: salvations or frustrations? J Vasc Surg. 2011;53(5):1429-30. doi:10.1016/j.jvs.2011.02.024.
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psnet.ahrq.gov/issue/hospital-checklists-are-meant-save-lives-so-why-do-they-often-fail
July 31, 2013 - Newspaper/Magazine Article
Hospital checklists are meant to save lives—so why do they often fail?
Citation Text:
Anthes E. Hospital checklists are meant to save lives - so why do they often fail? Nature. 2015;523(7562):516-8. doi:10.1038/523516a.
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psnet.ahrq.gov/issue/trainees-voice-recognising-importance-preoperative-briefings-surgical-trainees
October 09, 2019 - Commentary
The trainee's voice: recognising the importance of preoperative briefings for surgical trainees.
Citation Text:
Bethune R, Blencowe NS. The trainee's voice: recognising the importance of preoperative briefings for surgical trainees. J Perioper Pract. 2014;24(3):56-58.
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psnet.ahrq.gov/issue/redesigning-surgical-decision-making-high-risk-patients
July 20, 2016 - Commentary
Redesigning surgical decision making for high-risk patients.
Citation Text:
Glance LG, Osler T, Neuman MD. Redesigning surgical decision making for high-risk patients. N Engl J Med. 2014;370(15):1379-1381. doi:10.1056/NEJMp1315538.
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psnet.ahrq.gov/issue/how-surgical-trainees-handle-catastrophic-errors-qualitative-study
March 19, 2019 - Study
How surgical trainees handle catastrophic errors: a qualitative study.
Citation Text:
Balogun JA, Bramall AN, Bernstein M. How Surgical Trainees Handle Catastrophic Errors: A Qualitative Study. J Surg Educ. 2015;72(6):1179-84. doi:10.1016/j.jsurg.2015.05.003.
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psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - Despite Clues, Failed to Rescue
August 1, 2017
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
Case Objectives
Define failure to rescue.
Identify the main contributors to failure-to-rescue events.
Appreciate the ongoing areas of scien…