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psnet.ahrq.gov/issue/improving-patient-care-my-right-knee
August 04, 2021 - Commentary
Improving patient care. My right knee.
Citation Text:
Berwick DM. Improving patient care. My right knee. Ann Intern Med. 2005;142(2):121-5.
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Dow…
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psnet.ahrq.gov/issue/surgical-adverse-events-systematic-review
June 01, 2012 - Review
Surgical adverse events: a systematic review.
Citation Text:
Anderson O, Davis R, Hanna GB, et al. Surgical adverse events: a systematic review. Am J Surg. 2013;206(2):253-62. doi:10.1016/j.amjsurg.2012.11.009.
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psnet.ahrq.gov/issue/what-patient-really-taking-discrepancies-between-surgery-and-anesthesiology-preoperative
August 04, 2021 - Study
What is the patient really taking? Discrepancies between surgery and anesthesiology preoperative medication histories.
Citation Text:
Burda SA, Hobson D, Pronovost PJ. What is the patient really taking? Discrepancies between surgery and anesthesiology preoperative medication hist…
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www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/or-briefing-audit.html
December 01, 2017 - Operating Room Briefing and Debriefing Audit Tool
AHRQ Safety Program for Surgery
Introduction
Problem Statement
One of the strongest determinants of safety culture is whether local and hospital leadership respond to staff patient safety concerns. Frontline providers understand patient safety …
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh65-67.html
April 01, 2018 - Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection
Exhibits 65 to 67
Previous Page Next Page
Table of Contents
Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection
Executive Summary
Chapter 1. Administration
Chapter …
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psnet.ahrq.gov/issue/error-reduction-through-team-leadership-applying-aviations-crm-model-or
September 25, 2013 - Commentary
Error reduction through team leadership: applying aviation's CRM model in the OR.
Citation Text:
Healy GB, Barker J, Madonna G. Error reduction through team leadership: applying aviation's CRM model in the OR. Bull Am Coll Surg. 2006;91(2):10-5.
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psnet.ahrq.gov/issue/quality-and-safety-surgical-care
August 26, 2011 - Commentary
Quality and safety in surgical care.
Citation Text:
Polk HC, Birkmeyer JD, Hunt D, et al. Quality and safety in surgical care. Ann Surg. 2006;243(4):439-48.
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psnet.ahrq.gov/issue/cutting-out-human-error
February 25, 2009 - Commentary
Cutting out human error.
Citation Text:
Feinmann J. Cutting out human error. BMJ. 2008;337:a2370. doi:10.1136/bmj.a2370.
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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/node/43368/psn-pdf
October 01, 2014 - Improving safety and quality of care with enhanced
teamwork through operating room briefings.
October 1, 2014
Hicks CW, Rosen MA, Hobson DB, et al. Improving safety and quality of care with enhanced teamwork
through operating room briefings. JAMA Surg. 2014;149(8):863-8. doi:10.1001/jamasurg.2014.172.
https://psne…
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psnet.ahrq.gov/node/48073/psn-pdf
June 19, 2019 - Special Section on Human Factors and Ergonomics in the
Operating Room: Contributions That Advance Surgical
Practice.
June 19, 2019
Hallbeck MS, Paquet V, eds. Appl Ergon. 2019;78:248-308.
https://psnet.ahrq.gov/issue/special-section-human-factors-and-ergonomics-operating-room-contributions-
advance-surgical
Surg…
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psnet.ahrq.gov/node/837419/psn-pdf
June 15, 2022 - Implicit racial bias in pediatric orthopaedic surgery.
June 15, 2022
Guzek R, Goodbody CM, Jia L, et al. Implicit racial bias in pediatric orthopaedic surgery. J Pediatr Orthop.
2022;42(7):393-399. doi:10.1097/bpo.0000000000002170.
https://psnet.ahrq.gov/issue/implicit-racial-bias-pediatric-orthopaedic-surgery
Res…
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psnet.ahrq.gov/node/47186/psn-pdf
October 24, 2018 - Quality, Value, and Patient Safety in Orthopedic Surgery.
October 24, 2018
Azar FM, ed. Orthop Clin North Am. 2018;49(4):A1-A8,389-552.
https://psnet.ahrq.gov/issue/quality-value-and-patient-safety-orthopedic-surgery
Quality and value have intersecting influence on the safety of health care. Articles in this specia…
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psnet.ahrq.gov/node/74130/psn-pdf
December 01, 2021 - Malpractice cases in breast surgery: an assessment of
litigation involving surgeons.
December 1, 2021
Fan B, Pardo J, Yu-Moe CW, et al. Malpractice cases in breast surgery: an assessment of litigation
involving surgeons. Ann Surg Oncol. 2021;28(13):8109-8115. doi:10.1245/s10434-021-10236-2.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/37982/psn-pdf
July 12, 2010 - Successful implementation of the Department of Veterans
Affairs' National Surgical Quality Improvement Program in
the private sector: the Patient Safety in Surgery study.
July 12, 2010
Khuri SF, Henderson WG, Daley J, et al. Successful implementation of the Department of Veterans Affairs'
National Surgical Quality…
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hcup-us.ahrq.gov/datainnovations/2015HCUPStateDatabases04072017.pdf
April 07, 2017 - State Ambulatory Surgery and Services Databases
The SASD include encounter-level data for ambulatory surgeries
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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…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND_0283_03-10-2008.pdf
January 01, 2008 - Effective Health Care
Topic Number(s): 0049
Document Completion Date: 6-9-09
1
Results of Topic Selection Process & Next Steps
Laparoscopic adjustable gastric banding (LAGB) for metabolic conditions will go forward for refinement
as a comparative effectiveness or effectiveness review. The scop…
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psnet.ahrq.gov/issue/learning-ask-tough-questions-your-surgeon
August 17, 2016 - Newspaper/Magazine Article
Learning to ask tough questions of your surgeon.
Citation Text:
Learning to ask tough questions of your surgeon. Landro L.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-c.docx
June 02, 2025 - Strategy 2: Communicating to Improve Quality (Tool 3)
AHRQ Safety Program for Ambulatory Surgery
Implementation Guide
Appendix C. Addressing Physician Concerns With the Checklist
Common Concern
Response
Explanation
“I'm already safe, and I don't need to use a tool like the checklist.”
“You are safe, but we …