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psnet.ahrq.gov/issue/reports-hospital-and-asc-performance
October 02, 2024 - Book/Report
Reports on Hospital and ASC Performance.
Citation Text:
Reports On Hospital And Asc Performance. Washington DC: The Leapfrog Group; September 2024.
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - Missed CANDOR Implementation Opportunities.
November 16, 2022
Schweitzer L. Missed CANDOR Implementation Opportunities. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
The Case
A 58-year-old man with a history of type 2 diabetes mellitus, hypertension, morbid obesit…
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psnet.ahrq.gov/node/33785/psn-pdf
May 01, 2015 - In Conversation With… John D. Birkmeyer, MD
May 1, 2015
In Conversation With… John D. Birkmeyer, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
Editor's note: John D. Birkmeyer, MD, is an internationally recognized health services researcher with
expertise in perfo…
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psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
September 15, 2024 - Retained Surgical Items: Definition and Epidemiology.
Citation Text:
Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - Missed CANDOR Implementation Opportunities.
Citation Text:
Schweitzer L. Missed CANDOR Implementation Opportunities.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/issue/collapse-sensemaking-organizations-mann-gulch-disaster
May 21, 2019 - Commentary
Classic
The collapse of sensemaking in organizations: the Mann Gulch disaster.
Citation Text:
Weick KE. The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster. Admin Sci Q. 2006;38(4):628-652. doi:10.2307/2393339.
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psnet.ahrq.gov/issue/prospective-validation-classification-intraoperative-adverse-events-classintra-international
November 20, 2015 - Study
Prospective validation of classification of intraoperative adverse events (ClassIntra): international, multicentre cohort study.
Citation Text:
Dell-Kuster S, Gomes NV, Gawria L, et al. Prospective validation of classification of intraoperative adverse events (ClassIntra): internat…
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psnet.ahrq.gov/issue/often-overlooked-problems-handoffs-intensive-care-unit-operating-room
May 25, 2016 - Review
Often overlooked problems with handoffs: from the intensive care unit to the operating room.
Citation Text:
Evans AS, Yee M-S, Hogue CW. Often overlooked problems with handoffs: from the intensive care unit to the operating room. Anesth Analg. 2014;118(3):687-9. doi:10.1213/ANE.00…
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psnet.ahrq.gov/issue/detection-adverse-events-surgical-patients-using-trigger-tool-approach
February 15, 2011 - Study
Detection of adverse events in surgical patients using the Trigger Tool approach.
Citation Text:
Griffin FA, Classen DC. Detection of adverse events in surgical patients using the Trigger Tool approach. Qual Saf Health Care. 2008;17(4):253-258. doi:10.1136/qshc.2007.025080.
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psnet.ahrq.gov/issue/how-much-and-what-local-adaptation-acceptable-comparison-24-surgical-safety-checklists
July 27, 2022 - Study
How much and what local adaptation is acceptable? A comparison of 24 surgical safety checklists in Switzerland.
Citation Text:
Fridrich A, Imhof A, Schwappach DLB. How much and what local adaptation is acceptable? A comparison of 24 surgical safety checklists in Switzerland. J Pati…
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psnet.ahrq.gov/issue/surfacing-safety-hazards-using-standardized-operating-room-briefings-and-debriefings-large
January 03, 2017 - Study
Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center.
Citation Text:
Bandari J, Schumacher K, Simon M, et al. Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional …
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psnet.ahrq.gov/issue/identification-common-themes-never-events-data-published-nhs-england
April 07, 2021 - Study
Identification of common themes from never events data published by NHS England.
Citation Text:
Omar I, Graham Y, Singhal R, et al. Identification of common themes from never events data published by NHS England. World J Surg. 2021;45(3):697-704. doi:10.1007/s00268-020-05867-7.
C…
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psnet.ahrq.gov/issue/perspectives-perioperative-team-based-morbidity-and-mortality-conferences-mixed-methods-study
October 11, 2023 - Study
Perspectives on perioperative team-based morbidity and mortality conferences: a mixed-methods study.
Citation Text:
Samost-Williams A, Rosen R, Cummins E, et al. Perspectives on Perioperative Team-Based Morbidity and Mortality Conferences: A Mixed Methods Study. Jt Comm J Qual Pati…
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psnet.ahrq.gov/issue/measuring-variation-use-who-surgical-safety-checklist-operating-room-multicenter-prospective
January 19, 2016 - Study
Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study.
Citation Text:
Russ S, Rout S, Caris J, et al. Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicente…
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psnet.ahrq.gov/issue/surgical-team-member-assessment-safety-surgery-practice-38-south-carolina-hospitals
May 11, 2016 - Study
Surgical team member assessment of the safety of surgery practice in 38 South Carolina hospitals.
Citation Text:
Singer SJ, Jiang W, Huang LC, et al. Surgical team member assessment of the safety of surgery practice in 38 South Carolina hospitals. Med Care Res Rev. 2015;72(3):298-3…
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psnet.ahrq.gov/issue/first-year-analysis-operating-room-black-box-study
October 16, 2019 - Study
Emerging Classic
First-year analysis of the Operating Room Black Box study.
Citation Text:
Jung JJ, Jüni P, Lebovic G, et al. First-year Analysis of the Operating Room Black Box Study. Ann Surg. 2020;271(1):122-127. doi:10.1097/SLA.0000000000002863.
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psnet.ahrq.gov/issue/where-are-my-instruments-hazards-delivery-surgical-instruments
September 25, 2008 - Study
Where are my instruments? Hazards in delivery of surgical instruments.
Citation Text:
Guédon ACP, Wauben LSGL, van der Eijk AC, et al. Where are my instruments? Hazards in delivery of surgical instruments. Surg Endosc. 2016;30(7):2728-35. doi:10.1007/s00464-015-4537-7.
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psnet.ahrq.gov/issue/impact-staff-turnover-during-cardiac-surgical-procedures
November 06, 2019 - Study
Impact of staff turnover during cardiac surgical procedures.
Citation Text:
Bloom JP, Moonsamy P, Gartland RM, et al. Impact of staff turnover during cardiac surgical procedures. J Thorac Cardiovasc Surg. 2019. doi:10.1016/j.jtcvs.2019.11.051.
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psnet.ahrq.gov/issue/checkpoint-simple-tool-measure-surgical-safety-checklist-implementation-fidelity
December 06, 2023 - Study
CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity.
Citation Text:
Moyal-Smith R, Etheridge JC, Turley N, et al. CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity. BMJ Qual Saf. 2024;33(4):223-231. doi:10.1136…
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psnet.ahrq.gov/issue/preventing-surgical-site-infections-are-safety-climate-level-and-its-strength-associated-self
July 19, 2023 - Study
Preventing surgical site infections: are safety climate level and its strength associated with self-reported commitment to, subjective norms toward, and knowledge about preventive measures?
Citation Text:
Pfeiffer Y, Atkinson A, Maag J, et al. Preventing surgical site infections: a…