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psnet.ahrq.gov/issue/systematic-review-identify-factors-affect-failure-rescue-and-escalation-care-surgery
September 09, 2015 - Review
A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery.
Citation Text:
Johnston MJ, Arora S, King D, et al. A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery. Surgery. 20…
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psnet.ahrq.gov/issue/barriers-implementation-checklists-office-based-procedural-setting
February 18, 2019 - Study
Barriers to the implementation of checklists in the office-based procedural setting.
Citation Text:
Shapiro FE, Fernando RJ, Urman RD. Barriers to the implementation of checklists in the office-based procedural setting. J Healthc Risk Manag. 2014;33(4):35-43. doi:10.1002/jhrm.21141…
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psnet.ahrq.gov/node/74719/psn-pdf
February 02, 2022 - Failure to rescue following emergency surgery: a FRAM
analysis of the management of the deteriorating patient.
February 2, 2022
Sujan M, Bilbro N, Ross A, et al. Failure to rescue following emergency surgery: A FRAM analysis of the
management of the deteriorating patient. Appl Ergon. 2022;98:103608. doi:10.1016/j.a…
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psnet.ahrq.gov/node/35300/psn-pdf
March 04, 2011 - How strong is the evidence for the use of perioperative
beta blockers in non-cardiac surgery? Systematic review
and meta-analysis of randomised controlled trials.
March 4, 2011
Devereaux PJ, Beattie WS, Choi PT-L, et al. How strong is the evidence for the use of perioperative ?
blockers in non-cardiac surgery? Sys…
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psnet.ahrq.gov/node/864378/psn-pdf
March 13, 2024 - Investigating workplace support and the importance of
psychological safety in general surgery residency
training.
March 13, 2024
Ojute F, Gonzales PA, Berler M, et al. Investigating workplace support and the importance of psychological
safety in general surgery residency training. J Surg Educ. 2024;81(4):514-524.
…
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psnet.ahrq.gov/node/50622/psn-pdf
November 06, 2019 - Starting elective cardiac surgery after 3 pm does not
impact patient morbidity, mortality, or hospital costs.
November 6, 2019
Axtell AL, Moonsamy P, Melnitchouk S, et al. Starting elective cardiac surgery after 3 pm does not impact
patient morbidity, mortality, or hospital costs. J Thorac Cardiovasc Surg. 2019.
d…
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psnet.ahrq.gov/node/43809/psn-pdf
February 25, 2015 - Application of the aviation black box principle in pediatric
cardiac surgery: tracking all failures in the pediatric
cardiac operating room.
February 25, 2015
Bowermaster R, Miller M, Ashcraft T, et al. Application of the aviation black box principle in pediatric
cardiac surgery: tracking all failures in the pedia…
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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/node/47776/psn-pdf
August 20, 2021 - FDA Safety Communication: update--robotically-assisted
surgical devices in mastectomy.
August 20, 2021
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.
https://psnet.ahrq.gov/issue/fda-safety-communication-caution-when-using-robotically-assisted-surgical-
devices-womens
…
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psnet.ahrq.gov/node/45230/psn-pdf
July 20, 2016 - Outcomes are worse in US patients undergoing surgery
on weekends compared with weekdays.
July 20, 2016
Glance LG, Osler T, Li Y, et al. Outcomes are Worse in US Patients Undergoing Surgery on Weekends
Compared With Weekdays. Med Care. 2016;54(6):608-15. doi:10.1097/MLR.0000000000000532.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/34642/psn-pdf
June 24, 2015 - Human factor in cardiac surgery: errors and near misses
in a high technology medical domain.
June 24, 2015
Carthey J, de Leval MR, Reason JT. The human factor in cardiac surgery: errors and near misses in a high
technology medical domain. Ann Thorac Surg. 2001;72(1):300-5.
https://psnet.ahrq.gov/issue/human-factor…
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psnet.ahrq.gov/node/838075/psn-pdf
September 14, 2022 - Crisis recovery in surgery: error management and
problem solving in safety-critical situations.
September 14, 2022
Gogalniceanu P, Kunduzi B, Ruckley C, et al. Crisis recovery in surgery: error management and problem
solving in safety-critical situations. Surgery. 2022;172(2):537-545. doi:10.1016/j.surg.2022.03.007…
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psnet.ahrq.gov/node/39746/psn-pdf
August 11, 2010 - Analysis of adverse events in pediatric surgery using
criteria validated from the adult population: justifying the
need for pediatric-focused outcome measures.
August 11, 2010
Rice-Townsend S, Hall M, Jenkins KJ, et al. Analysis of adverse events in pediatric surgery using criteria
validated from the adult populat…
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psnet.ahrq.gov/node/60601/psn-pdf
June 17, 2020 - Prevalence, types, and sources of bullying reported by US
general surgery residents in 2019.
June 17, 2020
Zhang LM, Ellis RJ, Ma M, et al. Prevalence, types, and sources of bullying reported by US general surgery
residents in 2019. JAMA. 2020;323(20):2093-2095. doi:10.1001/jama.2020.2901.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/837308/psn-pdf
June 01, 2022 - Delays in diagnosis, treatment, and surgery: root causes,
actions taken, and recommendations for healthcare
improvement.
June 1, 2022
Politi RE, Mills PD, Zubkoff L, et al. Delays in diagnosis, treatment, and surgery: root causes, actions taken,
and recommendations for healthcare improvement. J Patient Saf. 2022;1…
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psnet.ahrq.gov/node/35179/psn-pdf
June 06, 2016 - Patient safety in cataract surgery.
June 6, 2016
Kelly SP, Astbury NJ. Patient safety in cataract surgery. Eye (Lond). 2006;20(3):275-82.
https://psnet.ahrq.gov/issue/patient-safety-cataract-surgery
The authors evaluate patient safety issues involved with cataract surgery and provide several
recommendations for sa…
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psnet.ahrq.gov/node/39939/psn-pdf
June 27, 2018 - Hospitals collaborate to prevent wrong-site surgery.
June 27, 2018
Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.
https://psnet.ahrq.gov/issue/hospitals-collaborate-prevent-wrong-site-surgery
This article describes a wrong-site surgery prevention program and how it was succ…
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psnet.ahrq.gov/node/42278/psn-pdf
June 10, 2013 - Reducing errors in emergency surgery.
June 10, 2013
Watters DAK, Truskett PG. Reducing errors in emergency surgery. ANZ J Surg. 2013;83(6):434-437.
doi:10.1111/ans.12194.
https://psnet.ahrq.gov/issue/reducing-errors-emergency-surgery
In the context of emergency surgery, this review summarizes error classification,…
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psnet.ahrq.gov/node/42204/psn-pdf
June 10, 2013 - Quantifying and characterizing adverse events in
dermatologic surgery.
June 10, 2013
O'Neill JL, Lee YS, Solomon JA, et al. Quantifying and characterizing adverse events in dermatologic
surgery. Dermatol Surg. 2013;39(6):872-878. doi:10.1111/dsu.12165.
https://psnet.ahrq.gov/issue/quantifying-and-characterizing-ad…
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psnet.ahrq.gov/node/49419/psn-pdf
October 01, 2003 - The Other Side
October 1, 2003
Vincent CA. The Other Side. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/other-side
Case Objectives
List the factors contributing to wrong site surgery.
Understand the key components of the Universal Protocol for eliminating wrong site, wrong
procedure, wrong person surger…