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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary …
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psnet.ahrq.gov/web-mm/fire-hole-or-fire
August 03, 2017 - Fire in the Hole!—An OR Fire
Citation Text:
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
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psnet.ahrq.gov/web-mm/around-block
March 04, 2020 - Around the Block
Citation Text:
Minichiello T. Around the Block. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
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www.ahrq.gov/hai/tools/surgery/modules/implementation/ssi-bundle-slides.html
October 01, 2020 - Implementing Your Surgical Site Infection Prevention Bundle: Slide Presentation
AHRQ Safety Program for Surgery
Slide 1: AHRQ Safety Program for Surgery—Implementation
Implementing Your Surgical Site Infection Prevention Bundle
Slide 2: Learning Objectives
After this session, you will be able to–
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psnet.ahrq.gov/node/49848/psn-pdf
January 01, 2019 - Inadequate Preanesthetic Evaluation, Airway Trouble
November 1, 2018
Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
The Case
Case #1:
A 34-year-old woman was scheduled for a hysteroscopy under g…
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psnet.ahrq.gov/node/42193/psn-pdf
May 08, 2013 - Priority patient safety issues identified by perioperative
nurses.
May 8, 2013
Steelman VM, Graling PR, Perkhounkova Y. Priority patient safety issues identified by perioperative
nurses. AORN J. 2013;97(4):402-18. doi:10.1016/j.aorn.2012.06.016.
https://psnet.ahrq.gov/issue/priority-patient-safety-issues-identifie…
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digital.ahrq.gov/ahrq-funded-projects/patient-centered-postoperative-wound-surveillance-using-current-technology/citation/inter-rater
January 01, 2023 - Inter-rater agreement and checklist validation for postoperative wound assessment using smartphone images in vascular surgery.
Citation
Wiseman JT, Fernandes-Taylor S, Gunter R, et al. Inter-rater agreement and checklist validation for postoperative wound assessment using smartphone images in vascular…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/glaucoma-treatment_research-protocol.pdf
November 16, 2010 - Source: www.effectivehealthcare.ahrq.gov
Published Online: November 16, 2010
Evidence-based Practice Center Systematic Review Protocol
Project Title: Comparative Effectiveness of Treatment for Open-Angle Glaucoma
I. Background and Objectives for the Systematic Review
The Agency for Healthcare Research and…
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digital.ahrq.gov/ahrq-funded-projects/leveraging-health-information-technology-avoid-unnecessary-asymptomatic-carotid-revascularization/citation-3
January 01, 2023 - Gender-specific 30-day outcomes after carotid endarterectomy and carotid artery stenting in the Society for Vascular Surgery Vascular Registry.
Citation
Jim J, Dillavou ED, Upchurch GR Jr, et al. Gender-specific 30-day outcomes after carotid endarterectomy and carotid artery stenting in the Society fo…
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digital.ahrq.gov/ahrq-funded-projects/addressing-hospital-patient-information-needs-using-personal-health-record/citation-2
January 01, 2023 - Interactive tools for inpatient medication tracking: a multi-phase study with cardiothoracic surgery patients.
Citation
Wilcox L, Woollen J, Prey J, et al. Interactive tools for inpatient medication tracking: a multi-phase study with cardiothoracic surgery patients. J Am Med Inform Assoc 2016 Jan;23(1…
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www.ahrq.gov/research/findings/final-reports/stpra/stpraexh8.html
April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Exhibit 8. Example of an OR gate
Previous Page Next Page
Table of Contents
Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Executive Summary
Chapter 1. Introduction
Chapter 2. …
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www.ahrq.gov/research/findings/final-reports/stpra/stpraexh7.html
April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Exhibit 7. Example of an AND gate
Previous Page Next Page
Table of Contents
Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Executive Summary
Chapter 1. Introduction
Chapter 2.…
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www.ahrq.gov/research/findings/final-reports/stpra/stpraexh6.html
April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Exhibit 6. Steps involved in developing the fault tree model
Previous Page Next Page
Table of Contents
Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Executive Summary
Chapter 1…
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www.ahrq.gov/research/findings/final-reports/stpra/stpraexh1.html
April 01, 2018 - Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Exhibit 1. Relationship of data sources to the development of the ST-PRA
Previous Page Next Page
Table of Contents
Proactive Risk Assessment of Surgical Site Infection in Ambulatory Surgery Centers
Executive Summary…
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psnet.ahrq.gov/node/38453/psn-pdf
January 02, 2017 - A multidisciplinary team approach to retained foreign
objects.
January 2, 2017
Cima RR, Kollengode A, Storsveen AS, et al. A multidisciplinary team approach to retained foreign objects.
Jt Comm J Qual Saf. 2009;35(3):123-132.
https://psnet.ahrq.gov/issue/multidisciplinary-team-approach-retained-foreign-objects
Th…
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psnet.ahrq.gov/node/38486/psn-pdf
March 18, 2009 - Medical errors in orthopaedics. Results of an AAOS
member survey.
March 18, 2009
Wong DA, Herndon JH, Canale T, et al. Medical errors in orthopaedics. Results of an AAOS member
survey. J Bone Joint Surg Am. 2009;91(3):547-57. doi:10.2106/JBJS.G.01439.
https://psnet.ahrq.gov/issue/medical-errors-orthopaedics-result…
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psnet.ahrq.gov/node/38582/psn-pdf
May 22, 2023 - Serious Reportable Events in Massachusetts.
May 22, 2023
Fillo KT, Saunders K. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA:
Commonwealth of Massachusetts; 2023.
https://psnet.ahrq.gov/issue/serious-reportable-events-massachusetts
This reoccurring report compiles patient safety…
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psnet.ahrq.gov/node/39222/psn-pdf
January 13, 2010 - Surgical site signing and "time out": issues of compliance
or complacence.
January 13, 2010
Johnston G, Ekert L, Pally E. Surgical site signing and "time out": issues of compliance or complacence. J
Bone Joint Surg Am. 2009;91(11):2577-80. doi:10.2106/JBJS.H.01615.
https://psnet.ahrq.gov/issue/surgical-site-signin…
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psnet.ahrq.gov/node/45512/psn-pdf
October 05, 2016 - When doctors get the wrong patient.
October 5, 2016
Whitman E. Mod Healthc. September 25, 2016.
https://psnet.ahrq.gov/issue/when-doctors-get-wrong-patient
Misidentification of patients can result in problems such as medication administration delays, blood
transfusion mismatches, and wrong-patient surgery. This ma…
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digital.ahrq.gov/ahrq-funded-projects/optimizing-value-patient-reported-outcome-measures-improving-care-delivery/citation/outcomes
January 01, 2023 - What outcomes matter to patients after joint or spine surgery?
Citation
Whitebird RR, Solberg LI, Norton CK, Ziegenfuss JY, Asche SE, Grossman ES. What outcomes matter to patients after joint or spine surgery? J Patient Cent Res Rev. 2020 Apr 27;7(2):157-164. doi: 10.17294/2330-0698.1738. PMID: 323775…