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psnet.ahrq.gov/node/45522/psn-pdf
January 01, 2020 - Is communication improved with the implementation of an
obstetrical version of the World Health Organization safe
surgery checklist?
November 9, 2016
Govindappagari S, Guardado A, Goffman D, et al. Is Communication Improved With the Implementation of
an Obstetrical Version of the World Health Organization Safe Sur…
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psnet.ahrq.gov/node/37761/psn-pdf
May 14, 2008 - Student perceptions of medical errors: incorporating an
explicit professionalism curriculum in the third-year
surgery clerkship.
May 14, 2008
Newell P, Harris S, Aufses A, et al. Student perceptions of medical errors: incorporating an explicit
professionalism curriculum in the third-year surgery clerkship. J Surg …
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psnet.ahrq.gov/node/34861/psn-pdf
November 11, 2015 - When things go wrong: how health care organizations
deal with major failures.
November 11, 2015
Walshe K, Shortell SM. When things go wrong: how health care organizations deal with major failures.
Health Aff (Millwood). 2004;23(3):103-11.
https://psnet.ahrq.gov/issue/when-things-go-wrong-how-health-care-organizati…
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psnet.ahrq.gov/node/44833/psn-pdf
April 22, 2016 - The contribution of sociotechnical factors to health
information technology–related sentinel events.
April 22, 2016
Castro GM, Buczkowski L, Hafner JM. The Contribution of Sociotechnical Factors to Health Information
Technology-Related Sentinel Events. Jt Comm J Qual Patient Saf. 2016;42(2):70-76.
https://psnet.ah…
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psnet.ahrq.gov/node/43320/psn-pdf
September 26, 2016 - Identification and interference of intraoperative
distractions and interruptions in operating rooms.
September 26, 2016
Antoniadis S, Passauer-Baierl S, Baschnegger H, et al. Identification and interference of intraoperative
distractions and interruptions in operating rooms. J Surg Res. 2014;188(1):21-29.
doi:10.1…
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psnet.ahrq.gov/node/43058/psn-pdf
March 26, 2014 - A strategic approach to quality improvement and patient
safety education and resident integration in a general
surgery residency.
March 26, 2014
O'Heron CT, Jarman BT. A strategic approach to quality improvement and patient safety education and
resident integration in a general surgery residency. J Surg Educ. 2014…
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psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced
Respiratory Depression
May 27, 2020
Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-
…
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psnet.ahrq.gov/node/865373/psn-pdf
March 27, 2024 - In Conversation with...Patrick Tighe about Artificial
Intelligence
March 27, 2024
Tighe P. In Conversation with..Patrick Tighe about Artificial Intelligence . PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
Editor's note: Patrick Tighe, MD, MS…
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psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
May 16, 2022 - Medication Handling and Compounding Errors in the Operating Room.
Citation Text:
Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
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psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
January 29, 2021 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon
Citation Text:
Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
January 01, 2022 - Spotlight
Spotlight
Fecal Contamination of the Peritoneum from
Laparoscopic Trocar Injury: A Routine
Operation Goes Wrong
Source and Credits
• This presentation is based on the October 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary…
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psnet.ahrq.gov/perspective/conversation-david-urbach-md-msc
June 12, 2019 - In Conversation With… David Urbach, MD, MSc
April 1, 2015
Citation Text:
In Conversation With… David Urbach, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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…
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psnet.ahrq.gov/issue/guide-patient-and-family-engagement-environmental-scan-report
August 01, 2012 - Book/Report
Guide to Patient and Family Engagement: Environmental Scan Report.
Citation Text:
Guide to Patient and Family Engagement: Environmental Scan Report. Maurer M, Dardess P, Carman KL, Frazier K, Smeeding L. Rockville, MD: Agency for Healthcare Research and Quality; May 2012. AHR…
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psnet.ahrq.gov/issue/what-constitutes-effective-team-communication-after-error
September 23, 2020 - Commentary
What constitutes effective team communication after an error?
Citation Text:
Hart WM, Doerr P, Qian Y, et al. What constitutes effective team communication after an error? AMA J Ethics. 2020;22(4):E298-E304. doi:10.1001/amajethics.2020.298.
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Format:
…
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psnet.ahrq.gov/issue/aviation-tools-improve-patient-safety
June 19, 2024 - Commentary
Aviation tools to improve patient safety.
Citation Text:
Ross J. Aviation tools to improve patient safety. J Perianesth Nurs. 2014;29(6):508-10. doi:10.1016/j.jopan.2014.09.004.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML E…
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psnet.ahrq.gov/issue/preventing-retained-surgical-items
December 07, 2022 - Commentary
Preventing retained surgical items.
Citation Text:
Weston M, Chiodo C. Preventing retained surgical items. AORN J. 2022;115(6):569-575. doi:10.1002/aorn.13697.
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Format:
DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/issue/sleep-deprivation-call-institutional-rules
June 27, 2018 - Commentary
Sleep deprivation: a call for institutional rules.
Citation Text:
McKenna L, Kodner IJ, Healy GB, et al. Sleep deprivation: a call for institutional rules. Surgery. 2013;154(1):118-22.
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Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 X…
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psnet.ahrq.gov/issue/laparoscopic-bile-duct-injury-understanding-psychology-and-heuristics-error
May 29, 2014 - Study
Laparoscopic bile duct injury: understanding the psychology and heuristics of the error.
Citation Text:
Dekker SWA, Hugh TB. Laparoscopic bile duct injury: understanding the psychology and heuristics of the error. ANZ J Surg. 2008;78(12):1109-14. doi:10.1111/j.1445-2197.2008.0476…
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psnet.ahrq.gov/issue/operating-room-briefings
January 02, 2017 - Commentary
Operating room briefings.
Citation Text:
Makary MA, Holzmueller CG, Sexton B, et al. Operating room debriefings. Jt Comm J Qual Patient Saf. 2006;32(7):407-410, 357.
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Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
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psnet.ahrq.gov/issue/surgical-checklists-detailed-review-their-emergence-development-and-relevance-neurosurgical
September 29, 2017 - Review
Surgical checklists: a detailed review of their emergence, development, and relevance to neurosurgical practice.
Citation Text:
McConnell DJ, Fargen KM, Mocco J. Surgical checklists: A detailed review of their emergence, development, and relevance to neurosurgical practice. Surg…