- 
                                        
psnet.ahrq.gov/node/39047/psn-pdf October 28, 2009 - ProvenCare: quality improvement model for designing
highly reliable care in cardiac surgery.
October 28, 2009
Berry SA, Doll MC, McKinley KE, et al. ProvenCare: quality improvement model for designing highly
reliable care in cardiac surgery. Qual Saf Health Care. 2009;18(5):360-8. doi:10.1136/qshc.2007.025056.
htt…  
- 
                                        
psnet.ahrq.gov/node/45135/psn-pdf September 27, 2017 - Adverse events in robotic surgery: a retrospective study
of 14 years of FDA data.
September 27, 2017
Alemzadeh H, Raman J, Leveson N, et al. Adverse Events in Robotic Surgery: A Retrospective Study of 14
Years of FDA Data. PLoS One. 2016;11(4):e0151470. doi:10.1371/journal.pone.0151470.
https://psnet.ahrq.gov/issu…  
- 
                                        
psnet.ahrq.gov/node/45957/psn-pdf August 15, 2018 - Comparison of appendectomy outcomes between senior
general surgeons and general surgery residents.
August 15, 2018
Siam B, Al-Kurd A, Simanovsky N, et al. Comparison of Appendectomy Outcomes Between Senior General
Surgeons and General Surgery Residents. JAMA Surg. 2017;152(7):679-685.
doi:10.1001/jamasurg.2017.057…  
- 
                                        
psnet.ahrq.gov/issue/understanding-patient-and-clinician-reported-nonroutine-events-ambulatory-surgery December 16, 2020 - Study 
 
 
 
 
 
 
 
 
 
 Understanding patient and clinician reported nonroutine events in ambulatory surgery. 
 
 
 
 
 Citation Text: 
 Salwei ME, Anders S, Slagle JM, et al. Understanding patient and clinician reported nonroutine events in ambulatory surgery. J Patient Saf. 2023;19(2):e38-e45. doi:10.1097/pts.00000…  
- 
                                        
psnet.ahrq.gov/issue/association-hydrocodone-schedule-change-opioid-prescriptions-following-surgery June 07, 2017 - Study 
 
 
 
 
 
 
 
 
 
 Association of hydrocodone schedule change with opioid prescriptions following surgery. 
 
 
 
 
 Citation Text: 
 Habbouche J, Lee JS, Steiger R, et al. Association of Hydrocodone Schedule Change With Opioid Prescriptions Following Surgery. JAMA Surg. 2018;153(12):1111-1119. doi:10.1001/jamas…  
- 
                                        
psnet.ahrq.gov/issue/design-and-impact-novel-surgery-specific-second-victim-peer-support-program March 09, 2022 - Study 
 
 
 
 
 
 
 
 
 
            Emerging Classic
           
 
 Design and impact of a novel surgery-specific second victim peer support program.  
 
 
 
 
 Citation Text: 
 El Hechi MW, Bohnen JD, Westfal M, et al. Design and Impact of a Novel Surgery-Specific Second Victim Peer Support Program. J Am Coll Surg. 2…  
- 
                                        
psnet.ahrq.gov/issue/human-factor-cardiac-surgery-errors-and-near-misses-high-technology-medical-domain June 09, 2010 - Review 
 
 
 
 
 
 
 
 
 
            Classic
           
 
 Human factor in cardiac surgery: errors and near misses in a high technology medical domain. 
 
 
 
 
 Citation Text: 
 Carthey J, de Leval MR, Reason JT. The human factor in cardiac surgery: errors and near misses in a high technology medical domain. Ann Tho…  
- 
                                        
digital.ahrq.gov/ahrq-funded-projects/scalable-digital-communication-intervention-support-older-adults-and-care January 01, 2024 - Scalable Digital Communication Intervention to Support Older Adults and Care Partners Transitioning Home After Major Surgery 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Project Description 
 
 
 Publications 
 
 
 
 
 
 
 Creating a mobile application to support care transitions for older adults after surgery has the potential to prov…  
- 
                                        
psnet.ahrq.gov/node/44204/psn-pdf June 17, 2015 - Effectiveness of interventions to improve patient
handover in surgery: a systematic review.
June 17, 2015
Pucher PH, Johnston MJ, Aggarwal R, et al. Effectiveness of interventions to improve patient handover in
surgery: A systematic review. Surgery. 2015;158(1):85-95. doi:10.1016/j.surg.2015.02.017.
https://psnet.…  
- 
                                        
psnet.ahrq.gov/node/44170/psn-pdf May 29, 2023 - Ambulatory Surgery Center Survey on Patient Safety
Culture.
May 29, 2023
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
https://psnet.ahrq.gov/issue/ambulatory-surgery-center-survey-patient-safety-culture
Ambulatory surgery centers (ASCs) are increasingly being used to provide surgical ca…  
- 
                                        
psnet.ahrq.gov/node/41718/psn-pdf October 03, 2012 - Duty hours, quality of care, and patient safety: general
surgery resident perceptions.
October 3, 2012
Borman KR, Jones AT, Shea JA. Duty hours, quality of care, and patient safety: general surgery resident
perceptions. J Am Coll Surg. 2012;215(1):70-7; discussion 77-9. doi:10.1016/j.jamcollsurg.2012.02.010.
https…  
- 
                                        
psnet.ahrq.gov/node/46725/psn-pdf April 11, 2018 - Are we missing the near misses in the OR?
Underreporting of safety incidents in pediatric surgery.
April 11, 2018
Hamilton EC, Pham DH, Minzenmayer AN, et al. Are we missing the near misses in the OR?-
underreporting of safety incidents in pediatric surgery. J Surg Res. 2018;221:336-342.
doi:10.1016/j.jss.2017.08.…  
- 
                                        
psnet.ahrq.gov/node/43868/psn-pdf February 04, 2015 - Implementing a standardized safe surgery program
reduces serious reportable events.
February 4, 2015
Loftus T, Dahl D, OHare B, et al. Implementing a standardized safe surgery program reduces serious
reportable events. J Am Coll Surg. 2015;220(1):12-17.e3. doi:10.1016/j.jamcollsurg.2014.09.018.
https://psnet.ahrq.…  
- 
                                        
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/surgical-complication-prevention/glucose_control_factsheet.docx December 01, 2017 - Glucose Control Factsheet
Glucose Control Factsheet
Facts About Glucose Control and the Prevention of Surgical Site Infections 
Definition of Tight Glucose Control
Tight glucose control refers to getting as close to a normal (nondiabetic) blood glucose level as you safely can. Ideally, this means levels between 70 an…  
- 
                                        
www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/guide-measurement.html November 01, 2017 - Creating a Culture of Safety in the Ambulatory Surgery Environment: Implementation Guide 
 Measurement 
 
 
 
 
 Previous Page Next Page 
 
 Table of Contents 
 
 Creating a Culture of Safety in the Ambulatory Surgery Environment: Implementation Guide 
 Overview 
 The Comprehensive Unit-based Safety Program (CUSP) 
 Me…  
- 
                                        
www.ahrq.gov/research/findings/final-reports/ssi/ssiexh38-40.html April 01, 2018 - Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection 
 Exhibits 38 to 40 
 
 
 
 
 Previous Page Next Page 
 
 Table of Contents 
 
 Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection 
 Executive Summary 
 Chapter 1. Administration 
 Chapter …  
- 
                                        
psnet.ahrq.gov/node/36177/psn-pdf April 19, 2011 - Wrong site surgery.
April 19, 2011
Fraser SG, Adams W. Wrong site surgery. Br J Ophthalmol. 2006;90(7):814-6.
https://psnet.ahrq.gov/issue/wrong-site-surgery
The authors provide an overview of wrong site surgery, with special attention to incidents in ophthalmology.
https://psnet.ahrq.gov/issue/wrong-site-surgery 
- 
                                        
psnet.ahrq.gov/node/45664/psn-pdf July 02, 2017 - Intraoperative adverse events in abdominal surgery: what
happens in the operating room does not stay in the
operating room.
July 2, 2017
Bohnen JD, Mavros MN, Ramly EP, et al. Intraoperative Adverse Events in Abdominal Surgery: What
Happens in the Operating Room Does Not Stay in the Operating Room. Ann Surg. 2017;…  
- 
                                        
psnet.ahrq.gov/node/46390/psn-pdf October 29, 2017 - Using data to enhance performance and improve quality
and safety in surgery.
October 29, 2017
Goldenberg MG, Jung JJ, Grantcharov T. Using Data to Enhance Performance and Improve Quality and
Safety in Surgery. JAMA Surg. 2017;152(10):972-973. doi:10.1001/jamasurg.2017.2888.
https://psnet.ahrq.gov/issue/using-data-…  
- 
                                        
psnet.ahrq.gov/node/44520/psn-pdf September 30, 2015 - Patient safety in dermatologic surgery: parts 1 and 2.
September 30, 2015
Lolis M, Dunbar SW, Goldberg DJ, et al. J Am Acad Dermatol. 2015;73(1):1-26.
https://psnet.ahrq.gov/issue/patient-safety-dermatologic-surgery-part-1-patient-safety-procedural-
dermatology-part-2
This two-part review series explores patient s…