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psnet.ahrq.gov/issue/examination-factors-predict-perioperative-culture-safety
May 12, 2021 - Study
An examination of factors that predict the perioperative culture of safety.
Citation Text:
Wright MI, Polivka B, Abusalem S. An examination of factors that predict the perioperative culture of safety. AORN J. 2021;113(5):465-475. doi:10.1002/aorn.13373.
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psnet.ahrq.gov/issue/safety-performance-and-satisfaction-outcomes-operating-room-literature-review
April 03, 2019 - Review
Emerging Classic
Safety, performance, and satisfaction outcomes in the operating room: a literature review.
Citation Text:
Joseph A, Bayramzadeh S, Zamani Z, et al. Safety, Performance, and Satisfaction Outcomes in the Operating Room: A Literature Review.…
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Unfortunately, because of prolonged surgeries, the case was pushed to the end of the day.
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psnet.ahrq.gov/node/33670/psn-pdf
July 01, 2008 - Wrong site surgeries are a pretty good example of this—they happen to every big
institution a few times
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psnet.ahrq.gov/node/33662/psn-pdf
January 01, 2008 - For example, how many wrong-site, wrong-side
surgeries did they have, and then come up with the policies
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psnet.ahrq.gov/node/60173/psn-pdf
March 30, 2020 - For example, with regards to retained foreign
bodies and wrong site surgeries, I remember thinking when
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
September 01, 2014 - His pain was long-standing and related to multiple prior neck and back surgeries.
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psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
January 01, 2023 - The
severity of the burns required four skin grafts and nearly two dozen laser
surgeries.
7
CHALLENGING
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psnet.ahrq.gov/web-mm/its-sarah-not-stephen
January 01, 2015 - In general, transgender persons who have not undergone gender-affirmative surgeries or used hormonal
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psnet.ahrq.gov/node/866395/psn-pdf
July 23, 2024 - Rescue Improvement Conference Innovation Summary
July 23, 2024
https://psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
Summary
The Rescue Improvement Conference (RIC)1 was designed at the University of Michigan to address failure
to rescue with a particular focus on communication and com…
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - SPOTLIGHT CASE
Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression
Citation Text:
Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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psnet.ahrq.gov/node/851188/psn-pdf
July 05, 2023 - The role of an assistant nurse in implementing the WHO
Surgical Safety Checklist: perception and perspectives.
July 5, 2023
Ališi? E, Krupi? M, Ali? J, et al. The role of an assistant nurse in implementing the WHO Surgical Safety
Checklist: perception and perspectives. Cureus. 2023;15(5):e38854. doi:10.7759/cureus.…
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psnet.ahrq.gov/node/40020/psn-pdf
September 20, 2011 - Case 34-2010: a 65-year-old woman with an incorrect
operation on the left hand.
September 20, 2011
Ring DC, Herndon JH, Meyer GS. Case records of The Massachusetts General Hospital: Case 34-2010: a
65-year-old woman with an incorrect operation on the left hand. N Engl J Med. 2010;363(20):1950-7.
doi:10.1056/NEJMcp…
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psnet.ahrq.gov/node/60550/psn-pdf
June 03, 2020 - Clinical efficacy of combined surgical patient safety
system and the World Health Organization's checklists in
surgery: a nonrandomized clinical trial.
June 3, 2020
Storesund A, Haugen AS, Flaatten H, et al. Clinical Efficacy of Combined Surgical Patient Safety System
and the World Health Organization’s Checklists…
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psnet.ahrq.gov/node/42699/psn-pdf
October 30, 2013 - A prospective, observational study of the effects of
implementation strategy on compliance with a surgical
safety checklist.
October 30, 2013
Hannam JA, Glass L, Kwon J, et al. A prospective, observational study of the effects of implementation
strategy on compliance with a surgical safety checklist. BMJ Qual Saf.…
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psnet.ahrq.gov/node/38243/psn-pdf
November 26, 2008 - Impact of preoperative briefings on operating room
delays.
November 26, 2008
Nundy S, Mukherjee A, Sexton B, et al. Impact of preoperative briefings on operating room delays: a
preliminary report. Arch Surg. 2008;143(11):1068-72. doi:10.1001/archsurg.143.11.1068.
https://psnet.ahrq.gov/issue/impact-preoperative-br…
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psnet.ahrq.gov/node/867045/psn-pdf
October 30, 2024 - The burden of healthcare utilization, cost, and mortality
associated with select surgical site infections.
October 30, 2024
Shambhu S, Gordon AS, Liu Y, et al. The burden of healthcare utilization, cost, and mortality associated
with select surgical site infections. Jt Comm J Qual Patient Saf. 2024;50(12):857-866.
…
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psnet.ahrq.gov/node/856587/psn-pdf
January 01, 2024 - Surgical leadership in a culture of safety: an inter-
professional study of metrics and tools for improving
clinical practice.
November 29, 2023
Gogalniceanu P, Kunduzi B, Ruckley C, et al. Surgical leadership in a culture of safety: an inter-
professional study of metrics and tools for improving clinical practice…
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psnet.ahrq.gov/node/43363/psn-pdf
September 12, 2016 - Escalation of care and failure to rescue: a multicenter,
multiprofessional qualitative study.
September 12, 2016
Johnston MJ, Arora S, King D, et al. Escalation of care and failure to rescue: a multicenter,
multiprofessional qualitative study. Surgery. 2014;155(6):989-94. doi:10.1016/j.surg.2014.01.016.
https://ps…
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psnet.ahrq.gov/node/846155/psn-pdf
March 15, 2023 - Reduction in omission events after implementing a rapid
response system: a mortality review in a department of
gastrointestinal surgery.
March 15, 2023
Olsen SL, Nedrebø BS, Strand K, et al. Reduction in omission events after implementing a Rapid
Response System: a mortality review in a department of gastrointesti…