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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
April 01, 2025 - of System Failure
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
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psnet.ahrq.gov/node/42294/psn-pdf
May 22, 2013 - Misdiagnosis is more common than drug errors or wrong-
site surgery.
May 22, 2013
Boodman SG. Washington Post. May 6, 2013.
https://psnet.ahrq.gov/issue/misdiagnosis-more-common-drug-errors-or-wrong-site-surgery
This newspaper article discusses the pervasive problem of diagnostic errors and reveals insights from
…
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psnet.ahrq.gov/node/49866/psn-pdf
June 01, 2019 - check vials and labels.(4) In a more recent
prospective study (3) using direct observation of 277 surgeries
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psnet.ahrq.gov/node/841468/psn-pdf
December 14, 2022 - Various
ancillary monitoring modalities used during some complex surgeries may have significant effects
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www.ahrq.gov/sites/default/files/wysiwyg/cpi/about/impact/ahrq-works.pdf
April 01, 2017 - analyses have also tracked trends in readmission
rates by payer type; inpatient versus outpatient surgeries
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www.ahrq.gov/cpi/about/impact/index.html
April 01, 2017 - HCUP analyses have also tracked trends in readmission rates by payer type; inpatient versus outpatient surgeries
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psnet.ahrq.gov/node/33623/psn-pdf
December 01, 2005 - Examples included deadly and costly misdiagnoses, sloppy
surgeries, and failed robotic ventures that
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psnet.ahrq.gov/node/43676/psn-pdf
November 12, 2014 - Is surgery safer at a teaching hospital?
November 12, 2014
Webster H. US News & World Report. October 27, 2014.
https://psnet.ahrq.gov/issue/surgery-safer-teaching-hospital
This magazine article explores whether receiving care at a teaching hospital affects patient safety and
highlights how the demands of the educ…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4f_combo_psi09-postophemorrhage-bestpractices.pdf
May 20, 2016 - Selected Best Practices and Suggestions for Improvement
Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4f
Selected Best Practices and Suggestions for Improvement
PSI 09: Postoperative Hemorrhage or Hematoma
Why Focus on Postoperative Hemorrhage and Hemat…
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hcup-us.ahrq.gov/db/state/sasddist/sasddist_filecompmd.jsp
August 01, 2006 - SASD File Composition - Maryland
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
Contact Us
Espanol
FAQs
Email Updates …
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-194-section-1-tables-1-5.pdf
June 02, 2025 - CHIPRA 194: Section 1, Tables 1-5
1
Table 1 [=IMG1]: Codes to Identify Neuroimaging in Administrative Claims
Imaging Modality
Code Type
Codes
Computerized
Tomography (CT) of
Brain/Head
Revenue (UB-92)
350, 351, 352, 353, 354, 355, 356, 357, 358, 359
CPT 70450, 70460, 70470, 70480, 70481,70…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/surgery/9-senior-executives.pptx
June 01, 2023 - PowerPoint Presentation
AHRQ Safety Program for Improving
Surgical Care and Recovery
Engaging the Senior Executive
Presentation Template
AHRQ Pub. No. 23-0052
June 2023
Purpose and Use of This Presentation Template
Purpose of tool: To engage a senior leader to bridge the gap between senior management and frontline …
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psnet.ahrq.gov/node/43393/psn-pdf
July 30, 2014 - Effectiveness of the surgical safety checklist in correcting
errors: a literature review applying Reason's Swiss
cheese model.
July 30, 2014
Collins SJ, Newhouse R, Porter J, et al. Effectiveness of the surgical safety checklist in correcting errors: a
literature review applying Reason's Swiss cheese model. AORN J…
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psnet.ahrq.gov/node/40753/psn-pdf
September 07, 2011 - Preoperative surgical briefings do not delay operating
room start times and are popular with surgical team
members.
September 7, 2011
Ali M, Osborne A, Bethune R, et al. Preoperative surgical briefings do not delay operating room start times
and are popular with surgical team members. J Patient Saf. 2011;7(3):139-…
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psnet.ahrq.gov/node/38056/psn-pdf
June 09, 2011 - Ferrari's Formula One handovers and handovers from
surgery to intensive care.
June 9, 2011
Sower VE; Duffy JA; Kohers G; ASQ; American Society for Quality.
https://psnet.ahrq.gov/issue/ferraris-formula-one-handovers-and-handovers-surgery-intensive-care
This article describes the application of Formula One pit stop…
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psnet.ahrq.gov/issue/national-cluster-randomized-trial-duty-hour-flexibility-surgical-training
September 09, 2015 - Study
Classic
National cluster-randomized trial of duty-hour flexibility in surgical training.
Citation Text:
Bilimoria KY, Chung JW, Hedges L, et al. National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training. New Engl J Med. 2016;374(8):71…
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www.ahrq.gov/faqs/index.html
September 04, 2025 - Statistics on ambulatory surgeries are available for the combination of states in the State Ambulatory
-
www.ahrq.gov/faqs/index.html?page=0
Statistics on ambulatory surgeries are available for the combination of states in the State Ambulatory
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/040-ss-training-clinic-patient-ed.pptx
April 01, 2025 - Decolonize at Home
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
-
psnet.ahrq.gov/node/853773/psn-pdf
September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side.
September 27, 2023
Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
The Case
A first-year orthopedic surgery resident was consulted…