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psnet.ahrq.gov/issue/role-radio-frequency-detection-system-embedded-surgical-sponges-preventing-retained-surgical
February 13, 2008 - implementation study, investigators used sponges embedded with radio frequency detection (RFD) in emergency surgeries … May 27, 2009
Sponges, surgical instruments miscounted in 13% of surgeries.
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psnet.ahrq.gov/issue/assessment-incorrect-surgical-procedures-within-and-outside-operating-room-follow-study-us
October 24, 2018 - Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries … This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers
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psnet.ahrq.gov/issue/unplanned-return-theater-quality-care-and-risk-management-index
August 20, 2018 - of delayed diagnosis , researchers examined a retrospective case series of orthopedic and trauma surgeries … The authors advocate for a registry of unplanned return surgeries as a patient safety improvement strategy
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/58-frontline-presentation-template.docx
June 01, 2023 - When our team conducted our gap analysis for [service line] surgeries in CY[XXXX], we found that we performed … Bowel Preparation
For surgeries with a planned bowel resection, have bowel prep and oral antibiotics … receiving multimodal pain management
Regional analgesia protocol, if relevant
VTE Prophylaxis
For specific surgeries
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psnet.ahrq.gov/issue/surgery-safer-teaching-hospital
September 28, 2016 - January 30, 2019
5 cataract surgeries, 5 people blinded: what went wrong? … August 21, 2013
Doctors perform thousands of unnecessary surgeries.
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psnet.ahrq.gov/issue/surgery-clinic-rush-save-joan-riverss-life
November 14, 2012 - May 4, 2022
5 cataract surgeries, 5 people blinded: what went wrong? … February 5, 2014
Doctors perform thousands of unnecessary surgeries.
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psnet.ahrq.gov/issue/report-faults-childrens-hospital-medication-errors
August 24, 2016 - Copy Citation
Related Resources From the Same Author(s)
5 cataract surgeries … August 9, 2017
Fires during surgeries a bigger risk than thought.
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psnet.ahrq.gov/issue/geisinger-health-systems-plan-fix-americas-health-care
October 18, 2017 - June 1, 2011
MGH halts a pediatric program: Heart surgeries on hold after errors. … August 5, 2008
Quality of Care in Cranial Implant Surgeries at James A.
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www.ahrq.gov/research/findings/final-reports/ssi/ssi2.html
April 01, 2018 - We began with identifying candidate surgeries among VASQIP data from 2007 through 2009. … As VASQIP surgeries are identified by CPT code and not by ICD-9s, we built a map between the two for … Each type was categorized as to whether it could be consistent with each of the surgeries of interest … For example, a urine specimen was considered to be incompatible with an SSI from any of our surgeries … A wound swab was considered to be compatible with any of the surgeries.
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hcup-us.ahrq.gov/reports/statbriefs/statbriefs.jsp
July 01, 2025 - provide healthcare statistics on hospital inpatient stays, emergency department visits, and ambulatory surgeries
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hcup-us.ahrq.gov/db/nation/nass/nasscorrections_2022.jsp
January 01, 2022 - CORRECTIONS
Corrections to the National Ambulatory Surgery Sample 2022
Some in-scope ambulatory surgeries … (i.e., in-scope “narrow” surgeries that were started in the emergency department) may be over- or under-represented
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hcup-us.ahrq.gov/db/nation/neds/nedscorrections_2022.jsp
January 01, 2022 - – CORRECTIONS
Corrections to the Nationwide Emergency Department Sample 2022
Some ambulatory surgeries … (i.e., surgeries that were started in the emergency department) may be over- or under-represented in
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/impl-guide/implementation-guide-appendix-h.docx
June 02, 2025 - Catheters are indicated for:
· Acute urinary retention or obstruction
· Perioperative use in selected surgeries
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/106-cusp-psychological-safety.pptx
April 01, 2025 - Psychological Safety
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries … Speaking up about warming strategies might delay surgeries
Junior staff
| 6
Case Example
AHRQ Safety
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/asc-survey-english.pdf
June 02, 2025 - ASCs are facilities
where patients have surgeries, procedures, and treatments and are not expected to … ► Doctors means all physicians (MDs or DOs), podiatrists, dentists, and others who perform surgeries … Communication in the Surgery/Procedure Room
► Are you typically in the surgery/procedure room during surgeries
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psnet.ahrq.gov/node/861882/psn-pdf
January 31, 2024 - Safety Hazards in Ambulatory Surgery Centers
Additional safety hazards exist for surgeries or procedures … In the United States, more than 25 million surgeries each year are performed in ambulatory settings, … Additionally, educational materials and
tools were developed to address safety in ambulatory care surgeries … Beyond infections and complications from surgeries, researchers have begun to describe deviations from … optimal care in office-based surgeries from both patient and clinician perspectives.
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hcup-us.ahrq.gov/HCUP_Overview/HCUP_Overview/index508.jsp
September 01, 2025 - Are prostate surgeries coded exclusively for men? … Robert would like to study pediatric heart surgeries in children on a national-level. … or more broadly defined surgeries that include diagnostic invasive surgeries
Tools for ICD-9-CM … Tim should use the NIS to conduct this regional analysis on CABG surgeries. … Outpatient surgeries are captured in the SASD.
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psnet.ahrq.gov/issue/surgical-case-listing-accuracy-failure-analysis-high-volume-academic-medical-center
September 25, 2011 - Wrong-site surgeries are a rare yet devastating complication for patients. … While no wrong-site surgeries occurred, there were nearly 800 cases where this potential was noted and
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psnet.ahrq.gov/issue/risk-factors-and-outcomes-foreign-body-left-during-procedure-analysis-413-incidents-after
December 04, 2016 - prior studies in adults have defined risk factors for retained instruments, which include emergency surgeries … Gynecologic surgeries emerged as the only type of surgery significantly associated with an increased
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psnet.ahrq.gov/issue/va-hospitals-flooded-complaints-about-care
August 09, 2017 - January 29, 2020
5 cataract surgeries, 5 people blinded: what went wrong? … August 24, 2016
Surgeons must tell patients of double-booked surgeries, new guidelines