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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4h_combo_psi11-postoprespfailure-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.4h
Selected Best Practices and Suggestions for Improvement
PSI 11: Postoperative Respiratory Failure
Why Focus on Postoperative Respiratory Failure? …
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
December 01, 2017 - PowerPoint Presentation: Learn From Defects for Sustainability
Sustainability: Learning From Defects
AHRQ Safety Program for Surgery
Sustainability
AHRQ Pub. No. 16(18)-0004-15-EF
December 2017
AHRQ Safety Program for Surgery – Sustainability
SAY:
This module will review some concepts from Learning From Defects Th…
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psnet.ahrq.gov/issue/better-care-surgical-patients-recognizing-and-responding-unexpected-save-lives
January 11, 2017 - Image/Poster
Better care for surgical patients: recognizing and responding to the unexpected to save lives.
Citation Text:
Better care for surgical patients: recognizing and responding to the unexpected to save lives. Ghaferi A. IHPI Brief. December 2019. &n…
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psnet.ahrq.gov/issue/noahs-story-please-listen
June 27, 2018 - Newspaper/Magazine Article
Noah's story: please listen.
Citation Text:
Noah's story: please listen. Lord T. Patient Saf Qual Healthc. March/April 2012;9:38-41,44.
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psnet.ahrq.gov/issue/simulation-based-surgical-education
August 19, 2015 - Special or Theme Issue
Simulation-based Surgical Education.
Citation Text:
Simulation-based Surgical Education. Surgery. 2015;158:1395-1440.
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psnet.ahrq.gov/issue/acting-concerns-your-professional-responsibility
April 02, 2014 - Book/Report
Acting on Concerns: Your Professional Responsibility.
Citation Text:
Acting on Concerns: Your Professional Responsibility. Shale S; The Royal College of Surgeons of England. London, UK: RCSENG Communications; 2013.
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psnet.ahrq.gov/node/36399/psn-pdf
May 04, 2015 - Tips for Safer Surgery.
May 4, 2015
Surgical Care Improvement Project. Oklahoma City, OK: Oklahoma Foundation for Medical Quality;
2006.
https://psnet.ahrq.gov/issue/tips-safer-surgery
This tip sheet provides a list of questions consumers should ask clinicians to help improve the safety of
their surgical car…
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psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
April 01, 2008 - Anticoagulation: Held Too Long
Citation Text:
Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/39591/psn-pdf
March 21, 2016 - Annual Benchmarking Report: Malpractice Risks in
Surgery.
March 21, 2016
Cambridge, MA: CRICO/RMF Strategies; 2010.
https://psnet.ahrq.gov/issue/annual-benchmarking-report-malpractice-risks-surgery
Analyzing data from 3300 surgical malpractice cases, this report describes errors across the continuum of
surgical c…
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psnet.ahrq.gov/issue/burden-healthcare-utilization-cost-and-mortality-associated-select-surgical-site-infections
October 09, 2024 - Study
The burden of healthcare utilization, cost, and mortality associated with select surgical site infections.
Citation Text:
Shambhu S, Gordon AS, Liu Y, et al. The burden of healthcare utilization, cost, and mortality associated with select surgical site infections. Jt Comm J Qual Pa…
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psnet.ahrq.gov/issue/disruptive-behavior-operating-room-prospective-observational-study-triggers-and-effects-tense
October 29, 2014 - Study
"Disruptive behavior" in the operating room: A prospective observational study of triggers and effects of tense communication episodes in surgical teams.
Citation Text:
Keller S, Tschan F, Semmer NK, et al. “Disruptive behavior” in the operating room: A prospective observational st…
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psnet.ahrq.gov/issue/relationship-emotional-climate-work-and-threat-patient-outcome-high-volume-thoracic-surgery
July 05, 2013 - Study
The relationship of the emotional climate of work and threat to patient outcome in a high-volume thoracic surgery operating room team.
Citation Text:
Nurok M, Evans LA, Lipsitz S, et al. The relationship of the emotional climate of work and threat to patient outcome in a high-vo…
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psnet.ahrq.gov/issue/successful-implementation-department-veterans-affairs-national-surgical-quality-improvement
March 28, 2012 - Study
Successful implementation of the Department of Veterans Affairs' National Surgical Quality Improvement Program in the private sector: the Patient Safety in Surgery study.
Citation Text:
Khuri SF, Henderson WG, Daley J, et al. Successful implementation of the Department of Veteran…
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psnet.ahrq.gov/issue/bariatric-surgery-operating-room-teams-stayed-fixed-during-day-multicenter-study-analyzing
December 21, 2014 - Study
Bariatric surgery with operating room teams that stayed fixed during the day: a multicenter study analyzing the effects on patient outcomes, teamwork and safety climate, and procedure duration.
Citation Text:
Stepaniak PS, Heij C, Buise MP, et al. Bariatric surgery with operating r…
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psnet.ahrq.gov/issue/leveraging-science-teamwork-sustain-handoff-improvements-cardiovascular-surgery
November 28, 2018 - Study
Leveraging the science of teamwork to sustain handoff improvements in cardiovascular surgery.
Citation Text:
Keebler JR, Lynch I, Ngo F, et al. Leveraging the science of teamwork to sustain handoff improvements in cardiovascular surgery. Jt Comm J Qual Patient Saf. 2023;49(8):373-3…
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psnet.ahrq.gov/issue/combined-teamwork-training-and-work-standardisation-intervention-operating-theatres
January 20, 2015 - Study
A combined teamwork training and work standardisation intervention in operating theatres: controlled interrupted time series study.
Citation Text:
Morgan L, Pickering S, Hadi M, et al. A combined teamwork training and work standardisation intervention in operating theatres: control…
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psnet.ahrq.gov/issue/box-ticking-black-box-evolution-operating-room-safety
October 29, 2017 - Commentary
From box ticking to the black box: the evolution of operating room safety.
Citation Text:
Goldenberg MG, Elterman D. From box ticking to the black box: the evolution of operating room safety. World J Urol. 2019;38(6):1369-1372. doi:10.1007/s00345-019-02886-5.
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psnet.ahrq.gov/issue/association-surgical-resident-wellness-medical-errors-and-patient-outcomes
November 20, 2019 - Study
Association of surgical resident wellness with medical errors and patient outcomes.
Citation Text:
Hewitt DB, Ellis RJ, Chung JW, et al. Association of surgical resident wellness with medical errors and patient outcomes. Ann Surg. 2021;274(2):396-402. doi:10.1097/sla.00000000000039…
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psnet.ahrq.gov/issue/prescription-opioid-analgesics-commonly-unused-after-surgery-systematic-review
March 30, 2022 - Review
Prescription opioid analgesics commonly unused after surgery: a systematic review.
Citation Text:
Bicket MC, Long JJ, Pronovost PJ, et al. Prescription Opioid Analgesics Commonly Unused After Surgery. JAMA Surg. 2017;152(11):1066-1071. doi:10.1001/jamasurg.2017.0831.
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psnet.ahrq.gov/issue/improving-patient-safety-operating-theatre-and-perioperative-care-obstacles-interventions-and
April 21, 2015 - Review
Improving patient safety in the operating theatre and perioperative care: obstacles, interventions, and priorities for accelerating progress.
Citation Text:
Sevdalis N, Hull L, Birnbach DJ. Improving patient safety in the operating theatre and perioperative care: obstacles, inter…