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psnet.ahrq.gov/node/33596/psn-pdf
January 29, 2025 - Failure to Rescue
January 29, 2025
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/failure-rescue
Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet
primers are regularly reviewed and updated to ensure that they reflect cur…
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psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
January 29, 2021 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.
Citation Text:
Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.. 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/which-end-which
February 09, 2011 - Which End Is Which?
Citation Text:
Campbell AR. Which End Is Which?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/issue/perioperative-patient-safety-correct-patient-correct-surgery-correct-side-multifaceted-cross
December 21, 2011 - Study
Perioperative patient safety: correct patient, correct surgery, correct side--a multifaceted, cross-organizational, interventional study.
Citation Text:
Zohar E, Noga Y, Davidson E, et al. Perioperative patient safety: correct patient, correct surgery, correct side--a multifacete…
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - His pain was long-standing and related to multiple prior neck and back surgeries.
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psnet.ahrq.gov/issue/operating-room-hazards-and-approaches-improve-patient-safety
September 13, 2023 - Review
Patient safety in the operating room.
Citation Text:
Patient safety in the operating room. Wahr JA. UpToDate. September 21, 2023.
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psnet.ahrq.gov/web-mm/or
August 22, 2013 - On O.R. Off?
Citation Text:
Leonard M. On O.R. Off?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/other-side
May 01, 2007 - SPOTLIGHT CASE
The Other Side
Citation Text:
Vincent CA. The Other Side. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/issue/effect-noise-auditory-processing-operating-room
November 16, 2022 - Study
Effect of noise on auditory processing in the operating room.
Citation Text:
Way J, Long A, Weihing J, et al. Effect of noise on auditory processing in the operating room. J Am Coll Surg. 2013;216(5):933-8. doi:10.1016/j.jamcollsurg.2012.12.048.
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psnet.ahrq.gov/issue/handbook-perioperative-and-procedural-patient-safety
December 01, 2021 - Book/Report
Handbook of Perioperative and Procedural Patient Safety.
Citation Text:
Handbook of Perioperative and Procedural Patient Safety. Sanchez JA, Higgins RSD, Kent PS, eds. St Louis, MO: Elsevier; 2024. ISBN: 9780323661799.
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psnet.ahrq.gov/issue/insurance-claims-wrong-side-wrong-organ-wrong-procedure-or-wrong-person-surgical-errors
October 20, 2021 - Study
Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years.
Citation Text:
Vacheron C-H, Acker A, Autran M, et al. Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors:…
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psnet.ahrq.gov/issue/compliance-and-barriers-implementing-surgical-safety-checklist-mixed-methods-study
October 06, 2021 - Study
Compliance with and barriers to implementing the surgical safety checklist: a mixed-methods study.
Citation Text:
Aydin Akbuga G, Sürme Y, Esenkaya D. Compliance with and barriers to implementing the surgical safety checklist: a mixed-methods study. AORN J. 2023;117(2):e1-e10. doi:…
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psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
April 28, 2021 - Procedural Mishap: Learning Curve?
Citation Text:
Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-errors-operating-room
January 29, 2021 - Is that solution for IV or irrigation?: Fluid administration errors in the operating room.
Citation Text:
Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - Failure to Rescue
Citation Text:
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/issue/special-section-human-factors-and-ergonomics-operating-room-contributions-advance-surgical
September 01, 2018 - Special or Theme Issue
Special Section on Human Factors and Ergonomics in the Operating Room: Contributions That Advance Surgical Practice.
Citation Text:
Special Section on Human Factors and Ergonomics in the Operating Room: Contributions That Advance Surgical Practice. Hallbeck MS, Paq…
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psnet.ahrq.gov/print/pdf/node/867659
July 10, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Rapid Response Systems
Curated Library
Primers
Rapid Response Systems
UC Davis PSNet Editorial Team | September, 15 2024
Rapid response teams represent an intuitively simple concept: when a patient demonstrates signs of
imminent clinical de…
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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - of skin or mucosa, non-penetrating soft tissue injuries, and even routine obstetric or gynecologic surgeries
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psnet.ahrq.gov/issue/evaluation-postoperative-handover-using-tool-assess-information-transfer-and-teamwork
April 30, 2014 - Study
Evaluation of postoperative handover using a tool to assess information transfer and teamwork.
Citation Text:
Evaluation of postoperative handover using a tool to assess information transfer and teamwork. Nagpal K, Abboudi M, Fischler L, et al. Ann Surg. 2011;253:831-837.
Co…
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psnet.ahrq.gov/training-catalog/international-conference-emerging-surgery-trends-2025-redefining-surgical
January 01, 2025 - International Conference on Emerging Surgery Trends 2025: Redefining Surgical Excellence Conference
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Organization:
Organization
The Research Ga…