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421. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42393/psn-pdf
     January 14, 2014 - Wrong site surgery in otolaryngology–head and neck surgery. … Wrong site surgery in otolaryngology-head and neck surgery. … https://psnet.ahrq.gov/issue/wrong-site-surgery-otolaryngology-head-and-neck-surgery This review discusses … https://psnet.ahrq.gov/issue/wrong-site-surgery-otolaryngology-head-and-neck-surgery https://psnet.ahrq.gov … /primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

422. Two Wrongs Don't Make a Right (Kidney) | PSNet
     psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
     April 01, 2010 - of wrong-site surgery. … with the surgery. … The Joint Commission defines wrong-site surgery as any surgery performed on the wrong site, any procedure … , it does not necessarily mean that surgery was performed at the incorrect level.( 2 ) Wrong-site surgery … No further surgery is performed at that level.

423. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49726/psn-pdf
     March 01, 2015 - of wrong-site surgery. … with the surgery. … The Joint Commission defines wrong-site surgery as any surgery performed on the wrong site, any procedure … , it does not necessarily mean that surgery was performed at the incorrect level.(2) Wrong-site surgery … No further surgery is performed at that level.

424. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35875/psn-pdf
     May 21, 2013 - Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. … https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person- surgery … According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per … The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery … to improve teamwork and decrease the overall risk of wrong-site surgery.

425. Failure to rescue deteriorating patients: a systematic review of root causes and improvement strategies. | PSNet
     psnet.ahrq.gov/issue/failure-rescue-deteriorating-patients-systematic-review-root-causes-and-improvement
     January 18, 2013 - study of the frequency, severity, and etiology of failures in postoperative care after major elective general … surgery. … A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery … September 12, 2016 Educational targets to reduce medication errors by general surgery … after implementing a rapid response system: a mortality review in a department of gastrointestinal surgery

426. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41778/psn-pdf
     January 18, 2013 - study of the frequency, severity, and etiology of failures in postoperative care after major elective general … surgery. … study of the frequency, severity, and etiology of failures in postoperative care after major elective general … surgery.

427. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38331/psn-pdf
     October 20, 2010 - Assessment of the implementation of a national patient safety alert to reduce wrong site surgery. … Assessment of the implementation of a national patient safety alert to reduce wrong site surgery. … ://psnet.ahrq.gov/issue/assessment-implementation-national-patient-safety-alert-reduce-wrong-site- surgery … Wrong-site surgery is a rare yet devastating outcome. … A past AHRQ WebM&M commentary discussed the factors contributing to a near-miss wrong-site surgery,

428. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46811/psn-pdf
     May 17, 2018 - A surgical procedure grid for safety and operating room communication in multisite surgery. … A Surgical Procedure Grid for Safety and Operating Room Communication in Multisite Surgery. … ://psnet.ahrq.gov/issue/surgical-procedure-grid-safety-and-operating-room-communication-multisite- surgery … This commentary describes a tool developed to decrease confusion in plastic surgery. … /issue/patient-safety-plastic-surgery-identifying-areas-quality-improvement-efforts

429. Turn the Other Cheek | PSNet
     psnet.ahrq.gov/web-mm/turn-other-cheek
     October 26, 2010 - On the day of surgery, standard preprocedure verification was completed. … The Joint Commission defines wrong-site surgery as any surgery performed on the wrong site or the wrong … Most published reports of dermatology-specific wrong-site surgery originate from Mohs surgery data. … guarding against cases of wrong-site surgery. … American Society for Dermatologic Surgery: Report of 2010 Procedures.

430. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41245/psn-pdf
     March 29, 2012 - The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board … of Orthopaedic Surgery. … The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board … of Orthopaedic Surgery. … The most common errors reported were related to wrong-level spine surgery.

431. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43867/psn-pdf
     March 11, 2015 - Applying fault tree analysis to the prevention of wrong- site surgery. … Applying fault tree analysis to the prevention of wrong-site surgery. … https://psnet.ahrq.gov/issue/applying-fault-tree-analysis-prevention-wrong-site-surgery This systematic … errors prior to surgery, intraoperative verification failures, and omitting steps in the verification … /issue/incidence-patterns-and-prevention-wrong-site-surgery https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

432. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39546/psn-pdf
     May 26, 2010 - Avoiding wrong site surgery: a systematic review. … Avoiding wrong site surgery: a systematic review. … proposes specific interventions to prevent wrong-site spinal surgery. … /wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery … https://psnet.ahrq.gov/issue/prevalence-wrong-level-surgery-among-spine-surgeons

433. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35868/psn-pdf
     July 10, 2008 - Incidence, patterns, and prevention of wrong-site surgery. … Incidence, patterns, and prevention of wrong-site surgery. Arch Surg. 2006;141(4):353-358. … https://psnet.ahrq.gov/issue/incidence-patterns-and-prevention-wrong-site-surgery This AHRQ-supported … /issue/statement-prevention-retained-foreign-bodies-after-surgery https://psnet.ahrq.gov/issue/what-correct-site-surgery … https://psnet.ahrq.gov/issue/what-correct-site-surgery

434. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49650/psn-pdf
     March 01, 2012 - On the day of surgery, standard preprocedure verification was completed. … Most published reports of dermatology-specific wrong-site surgery originate from Mohs surgery data. … guarding against cases of wrong-site surgery. … American Society for Dermatologic Surgery: Report of 2010 Procedures. … Outcome of 6 years of protocol use for preventing wrong site office surgery.

435. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41424/psn-pdf
     June 27, 2012 - learning and improvement: a two-year experience with the reporting of morbidity and mortality cases by general … surgery residents. … learning and improvement: a two-year experience with the reporting of morbidity and mortality cases by general … surgery residents.

436. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46853/psn-pdf
     February 22, 2019 - Outcomes with overlapping surgery at a large academic medical center. … Outcomes With Overlapping Surgery at a Large Academic Medical Center. … https://psnet.ahrq.gov/issue/outcomes-overlapping-surgery-large-academic-medical-center The practice … of overlapping surgery has raised significant concerns about patient safety. … /issue/safety-overlapping-surgery-high-volume-referral-center https://psnet.ahrq.gov/issue/association-overlapping-surgery-increased-risk-complications-following-hip-surgery

437. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44248/psn-pdf
     May 26, 2016 - Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never … Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires : A Systematic Review of Surgical Never … https://psnet.ahrq.gov/issue/wrong-site-surgery-retained-surgical-items-and-surgical-fires-systematic … Incidence estimates for retained surgical items and wrong-site surgery varied across studies, with median … /primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

438. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47714/psn-pdf
     March 27, 2019 - Quality improvement in ambulatory surgery centers: a major national effort aimed at reducing infections … Quality Improvement in Ambulatory Surgery Centers: A Major National Effort Aimed at Reducing Infections … https://psnet.ahrq.gov/issue/quality-improvement-ambulatory-surgery-centers-major-national-effort-aimed … - reducing Ambulatory surgery centers are increasingly utilized to provide surgical care to patients … They identified several barriers and conclude that the unique aspects of ambulatory surgery centers

439. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36632/psn-pdf
     July 28, 2010 - Operating room briefings and wrong-site surgery. … Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204(2):236-43. … https://psnet.ahrq.gov/issue/operating-room-briefings-and-wrong-site-surgery Although wrong-site surgeries … Protocol for prevention of wrong-site surgeries requires performing a "time out" before beginning surgery … /incidence-patterns-and-prevention-wrong-site-surgery https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

440. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49815/psn-pdf
     December 01, 2017 - He was scheduled for a preoperative evaluation prior to the date of surgery. … His blood counts and vital signs were closely monitored after surgery and he eventually stabilized. … , how far in advance of surgery to stop those medications, and when to resume them. … Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014;370:1494-1503. … Effectiveness of an electronic tool for medication reconciliation in a general surgery department.