-
psnet.ahrq.gov/node/43867/psn-pdf
March 11, 2015 - mitigate these vulnerabilities, suggesting that further
interventions are required to prevent wrong-site surgeries
-
psnet.ahrq.gov/node/44163/psn-pdf
October 13, 2015 - characterising-near-miss-events-complex-laparoscopic-surgery-through-video-
analysis
This series of blinded video reviews of laparoscopic surgeries
-
psnet.ahrq.gov/node/47157/psn-pdf
August 15, 2018 - Protocol are a widely accepted strategy for reducing wrong site, wrong
procedure, and wrong patient surgeries
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/097-ss-normothermia-one-pager.docx
April 01, 2025 - Normothermia
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Vane.pdf
February 01, 2005 - China Main,” 20 miles southwest of
Baghdad in the desert, was open April–August 2003 and performed 877 surgeries … CSH China Main renovated Ibn Sina Hospital (located in
Baghdad’s Green Zone), where another 1,255 surgeries … Surgeries included multiple traumas and burns. … Patient Safety During Military Deployments
471
Combat missions involved trauma and burn surgeries … Animal surgeries/CMS issues
Written plans should be readily available for all OR and CMS staff in the
-
psnet.ahrq.gov/issue/your-safer-surgery-survival-guide
November 15, 2024 - October 3, 2017
Surgeons must tell patients of double-booked surgeries, new guidelines
-
www.ahrq.gov/hai/cauti-tools/impl-guide/implementation-guide-appendix-g.html
October 01, 2015 - Perioperative use in selected surgeries.
-
digital.ahrq.gov/sites/default/files/docs/page/2006Reiling_052411comp.pdf
January 01, 2005 - op & post-op
infections
•Falls
•Transfusion events
•Deaths in restraints
•IP suicides
•Wrong site surgeries … Transfusion
events
–Deaths in
restraints
–Suicides
–Wrong tube-
connector-hole
events
–Wrong site
surgeries
-
psnet.ahrq.gov/node/45268/psn-pdf
September 27, 2016 - implementation study,
investigators used sponges embedded with radio frequency detection (RFD) in emergency surgeries
-
psnet.ahrq.gov/node/41958/psn-pdf
April 17, 2013 - psnet.ahrq.gov/issue/surgical-never-events-united-states
More than a decade ago, stories of wrong site surgeries
-
psnet.ahrq.gov/node/39893/psn-pdf
November 02, 2010 - However, this study finds that the volume–outcome relationship is limited to a few specific
surgeries
-
psnet.ahrq.gov/node/40145/psn-pdf
November 14, 2011 - This analysis of more than 6 million inpatient
surgeries identified risk factors for the development
-
psnet.ahrq.gov/node/38014/psn-pdf
March 02, 2011 - However, manual counting has
been criticized as ineffective and leading to prolonged surgeries.
-
psnet.ahrq.gov/node/46774/psn-pdf
April 12, 2019 - The number of surgeries in which a handoff occurred increased over time
during the 6-year study period
-
psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - Universal Protocol was designed to engage institutions in implementing a standardized
approach to surgeries … In fact, The Joint Commission sentinel event statistics
database reported 1072 wrong-site surgeries … widely when examining the literature and
accessible databases, ranging from 0.09 to 4.5 per 10,000 surgeries … Definitions and Examples of Wrong-Site Surgeries.(2)
Type Definition Example
Wrong Site
All surgical
-
www.ahrq.gov/hai/pfp/methods.html
December 01, 2017 - With Central Venous Catheters
MPSMS
Postoperative Cardiac Events for Cardiac and Noncardiac Surgeries … 4.00
5.25
0.76
All Other HACs
Postoperative Cardiac Events for Cardiac and Noncardiac Surgeries … 114,689
32,750,000
3.502
MPSMS
Postoperative Cardiac Events for Cardiac and Noncardiac Surgeries
-
hcup-us.ahrq.gov/reports/methods/2016-06.pdf
January 01, 2016 - Surgeries ........................................................................................... … Surgeries
4. … Surgeries
Kidney transplant
Possible HCUP databases NIS, SID
Complete capture in
HCUP databases? … Yes, although the investigator may need to consider whether to count
multiple cataract surgeries for … Surgeries
Table 3. Surgeries (continued)
Table 4.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/098-ss-hair-removal-one-pager.docx
April 01, 2025 - Preoperative Hair Removal
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/098-hair-removal-one-pager.docx
April 01, 2025 - Preoperative Hair Removal
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/096-ss-glycemic-control-one-pager.docx
April 01, 2025 - Glycemic Control
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries