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psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - Urologic/other surgeries on contiguous structures of genitourinary tract.
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psnet.ahrq.gov/web-mm/silent-pain-neck
August 19, 2020 - Silent Pain in the Neck
Citation Text:
Bittner EA. Silent Pain in the Neck. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/836712/psn-pdf
March 09, 2022 - Predictive power of the "trigger tool" for the detection of
adverse events in general surgery: a multicenter
observational validation study.
March 9, 2022
Pérez Zapata AI, Rodríguez Cuéllar E, de la Fuente Bartolomé M, et al. Predictive power of the "Trigger
Tool" for the detection of adverse events in general sur…
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psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
September 01, 2007 - For example, bariatric surgeons do gastric bypass surgeries that in the last decade have exploded in
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psnet.ahrq.gov/issue/bariatric-surgery-operating-room-teams-stayed-fixed-during-day-multicenter-study-analyzing
December 21, 2014 - Study
Bariatric surgery with operating room teams that stayed fixed during the day: a multicenter study analyzing the effects on patient outcomes, teamwork and safety climate, and procedure duration.
Citation Text:
Stepaniak PS, Heij C, Buise MP, et al. Bariatric surgery with operating r…
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psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
July 01, 2004 - Hip Fractures in Older Patients: the Case for Geriatrics Comanagement
Citation Text:
Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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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/issue/prevention-3-never-events-operating-room-fires-gossypiboma-and-wrong-site-surgery
February 10, 2012 - Review
Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.
Citation Text:
Zahiri HR, Stromberg J, Skupsky H, et al. Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. Surg Innov. 2011;18(1):55-…
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psnet.ahrq.gov/issue/multistep-approach-improving-biopsy-site-identification-dermatology-physician-staff-and
October 12, 2022 - Study
A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.
Citation Text:
Alam M, Lee A, Ibrahimi OA, et al. A multistep approach to improving biopsy site identification in dermatology: physician, st…
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psnet.ahrq.gov/clinical-areas
March 24, 2025 - Clinical Areas
Scroll down to search or browse using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the nurse care or medical specialty, featured in the resources.
Latest by Clinical Areas
In Conversation with Edwin Boudreaux about S…
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psnet.ahrq.gov/issue/using-performance-improvement-enhance-time-out-compliance-and-prevent-wrong-site-surgery
October 06, 2021 - Commentary
Using performance improvement to enhance time-out compliance and prevent wrong-site surgery.
Citation Text:
Vance ME, Proctor T, Schmidt KA. Using performance improvement to enhance time-out compliance and prevent wrong-site surgery. AORN J. 2021;113(6):635-642. doi:10.1002/ao…
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psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
September 25, 2019 - SPOTLIGHT CASE
Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery.
Citation Text:
Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research …
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psnet.ahrq.gov/web-mm/think-surgeon
December 04, 2024 - Think Like a Surgeon
Citation Text:
Cooper Z. Think Like a Surgeon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/topics-0
March 03, 2025 - Topics
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Featured Topics in Patient Safety
Updated Date: March 3, 2025
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psnet.ahrq.gov/issue/common-general-surgical-never-events-analysis-nhs-england-never-event-data
April 14, 2021 - Study
Common general surgical never events: analysis of NHS England never event data.
Citation Text:
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.…
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psnet.ahrq.gov/issue/handoff-protocol-cardiovascular-operating-room-cardiac-icu-associated-improvements-care
December 09, 2020 - Study
A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period.
Citation Text:
Kaufmnan J, Twite M, Barrett C, et al. A handoff protocol from the cardiovascular operating room to cardiac I…
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psnet.ahrq.gov/issue/outcome-differences-between-surgeons-performing-first-and-subsequent-coronary-artery-bypass
May 25, 2022 - Study
Outcome differences between surgeons performing first and subsequent coronary artery bypass grafting procedures in a day: a retrospective comparative cohort study.
Citation Text:
Zhang D, Gu D, Rao C, et al. Outcome differences between surgeons performing first and subsequent coron…
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psnet.ahrq.gov/issue/safer-paediatric-surgical-teams-5-year-evaluation-crew-resource-management-implementation-and
February 03, 2021 - Study
Safer paediatric surgical teams: a 5-year evaluation of crew resource management implementation and outcomes.
Citation Text:
Savage C, Gaffney A, Hussain-Alkhateeb L, et al. Safer paediatric surgical teams: A 5-year evaluation of crew resource management implementation and outcomes…
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psnet.ahrq.gov/issue/personal-protective-equipment-ppe-surgeons-during-covid-19-pandemic-systematic-review
September 23, 2020 - Review
Emerging Classic
Personal protective equipment (PPE) for surgeons during COVID-19 pandemic: a systematic review of availability, usage, and rationing.
Citation Text:
Jessop ZM, Dobbs TD, Ali SR, et al. Personal protective equipment for surgeons during COV…
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psnet.ahrq.gov/issue/artificial-intelligence-and-surgical-decision-making
September 11, 2019 - Review
Classic
Artificial intelligence and surgical decision-making.
Citation Text:
Loftus TJ, Tighe PJ, Filiberto AC, et al. Artificial intelligence and surgical decision-making. JAMA Surg. 2019;155(2):148-158. doi:10.1001/jamasurg.2019.4917.
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