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www.ahrq.gov/hai/tools/surgery/about.html
December 01, 2017 - About the Toolkit Development
The toolkit was developed as part of the AHRQ Safety Program for Surgery, a national implementation project to reduce surgical site infections and other complications in hospitals. The 3-year project brought together subject matter experts and participating hospitals across the co…
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psnet.ahrq.gov/topics-0
March 03, 2025 - Topics
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Featured Topics in Patient Safety
Updated Date: March 3, 2025
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/horizon-scan_research-2015.pdf
January 01, 2015 - A device intended to reduce the rate of second surgeries for patients undergoing lumpectomy for
breast … , if the device does in fact help to
avert second surgeries. … Assuming about 5% of surgical procedures are cervical disc
replacement surgeries, about 10,000 cervical … Institutions using MarginProbe to reduce second surgeries would
also lose the revenue stream they had … surgeries.
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digital.ahrq.gov/organization/cincinnati-childrens-hospital-medical-center
January 01, 2023 - Cincinnati Children's Hospital Medical Center
Optimal Methods for Notifying Clinicians About Epilepsy Surgery Patients
Description
This research prospectively evaluated a machine learning algorithm that identifies candidates for neurologic surgery to control epilepsy.
Gr…
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psnet.ahrq.gov/node/43045/psn-pdf
August 02, 2015 - A multistep approach to improving biopsy site
identification in dermatology: physician, staff, and patient
roles based on a Delphi consensus.
August 2, 2015
Alam M, Lee A, Ibrahimi OA, et al. A multistep approach to improving biopsy site identification in
dermatology: physician, staff, and patient roles based on a…
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psnet.ahrq.gov/node/38680/psn-pdf
August 18, 2010 - Improving safety in the operating room: a systematic
literature review of retained surgical sponges.
August 18, 2010
Wan W, Le T, Riskin L, et al. Improving safety in the operating room: a systematic literature review of
retained surgical sponges. Curr Opin Anaesthesiol. 2009;22(2):207-14.
doi:10.1097/ACO.0b013e32…
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psnet.ahrq.gov/node/837701/psn-pdf
July 20, 2022 - Pediatric surgical errors: a systematic scoping review.
July 20, 2022
Marsh KM, Fleming MA, Turrentine FE, et al. Pediatric surgical errors: a systematic scoping review. J
Pediatr Surg. 2022;57(4):616-621. doi:10.1016/j.jpedsurg.2021.07.019.
https://psnet.ahrq.gov/issue/pediatric-surgical-errors-systematic-scoping-…
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psnet.ahrq.gov/node/39550/psn-pdf
July 05, 2013 - A novel method for reproducibly measuring the effects of
interventions to improve emotional climate, indices of
team skills and communication, and threat to patient
outcome in a high-volume thoracic surgery center.
July 5, 2013
Nurok M, Lipsitz S, Satwicz P, et al. A novel method for reproducibly measuring the eff…
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psnet.ahrq.gov/node/48188/psn-pdf
August 14, 2019 - Analysis of human performance deficiencies associated
with surgical adverse events.
August 14, 2019
Suliburk JW, Buck QM, Pirko CJ, et al. Analysis of Human Performance Deficiencies Associated With
Surgical Adverse Events. JAMA Netw Open. 2019;2(7):e198067.
doi:10.1001/jamanetworkopen.2019.8067.
https://psnet.ahr…
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psnet.ahrq.gov/node/49485/psn-pdf
August 29, 2024 - Blind Spot
June 1, 2005
Lee LA. Blind Spot. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/blind-spot
The Case
A 36-year-old woman with no significant past medical history underwent right nephrectomy in the left lateral
position. The surgery was uncomplicated—her blood pressures intraoperatively were withi…
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www.ahrq.gov/sites/default/files/wysiwyg/data/3P-RD-Data-Dictionary.xlsx
June 02, 2025 - 3P_RD_AHRQ_PUF_Data_Dictionary
README
Physician Practice Research Database (3P-RD) Data Dictionary
Purpose of the 3P-RD Database
The purpose of the Physician and Physician Practice Research Databases (3P-RD) is to create a prototype database to address gaps in current physician and physician practice data at the s…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/availability/chipra-235-appendix-b.pdf
September 01, 2015 - CHIPRA 235: Appendix B: Examination of Credentials for Identified Specialists
Q-METRIC Availability of Specialty Services Measure 4, Access to Outpatient Specialty Care for Children: Appendix B Page 1
U18HS020516 Submitted September 2015
Validity Test 1b: Examination of Credentials for Identified Specialis…
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effectivehealthcare.ahrq.gov/sites/default/files/diabetes-horizon-scan-high-impact-1406.pdf
September 26, 2014 - Metabolic surgeries for T2DM are classified as purely restrictive, restrictive/malabsorptive, or
purely … This method is less invasive than some other metabolic
surgeries, and the resulting pouch for food … One research expert commented, “There is a greater significance of developing cataracts;
however, surgeries
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psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx
Spotlight
A Missed Bowel Perforation – the Importance of
Diagnostic Reasoning
Source and Credits
• This presentation is based on the September 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/web…
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psnet.ahrq.gov/node/866261/psn-pdf
July 10, 2024 - Missed Compartment Syndrome after Steep Lithotomy
Position for Laparoscopic Gynecological Surgery
July 10, 2024
Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic
Gynecological Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/missed-compartment-syndrome…
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effectivehealthcare.ahrq.gov/sites/default/files/10_obesity_potential_high_impact_2012-12-11.pdf
January 01, 2012 - potential to increase scientific understanding of the GI system and the mechanism of action of
bariatric surgeries
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psnet.ahrq.gov/clinical-areas
March 24, 2025 - Clinical Areas
Scroll down to search or browse using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the nurse care or medical specialty, featured in the resources.
Latest by Clinical Areas
In Conversation with Edwin Boudreaux about S…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cad-pci-bypass_executive.pdf
October 01, 2007 - Layout 1
Background
Atherosclerosis develops in a patchy,
discontinuous fashion within coronary
arteries. Therefore, it is possible to treat
the discrete areas of obstruction that most
impede coronary blood flow to the
myocardium. The mechanical approaches
to coronary revascularization fall broadly
into two categor…
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hcup-us.ahrq.gov/news/exhibit_booth/HCUPParticipationMap.pdf
February 09, 2022 - Slide 1
HCUP Partners Providing Inpatient Data
Updated 2/9/22
AK
RI
AZ
CA
UT
CT
FL
GA
IA
IL
KS
MA
MD
MO
NJ
NY
OR
PA
SC
TN
CO
WA
WI
VA
ME
MN
MI
NC
TX
KY
WV
NE
VT
NV OH
SD
AR
IN
NH
MT
ID
WY
ND
NM
OK
LA
MS AL
DE
HI
Inpatient
Data
Non-
participating
Partners
Providing:
D…
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www.ahrq.gov/cahps/surveys-guidance/item-sets/cg/suppl-decisionmaking-cg30-adult.html
November 01, 2017 - Supplemental Items for the CAHPS Clinician & Group Adult Survey 3.0: Shared Decisionmaking
Population version: Adult
Download these items: English (Word, 29 KB)
Users of the CAHPS Clinician & Group Survey are free to incorporate supplemental items in order to meet the needs of their organizations, local…