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441. 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

442. 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.

443. 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.

444. 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.

445. Tracking intraoperative complications. | PSNet
     psnet.ahrq.gov/issue/tracking-intraoperative-complications
     April 30, 2014 - Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery … February 17, 2015 Evaluation of critical incidents in general surgery. … April 21, 2015 Compliance with a time-out procedure intended to prevent wrong surgery … The Topic Operating Room Health Care Executives and Administrators Safety Scientists Surgery

446. Postoperative complications due to a retained surgical sponge. | PSNet
     psnet.ahrq.gov/issue/postoperative-complications-due-retained-surgical-sponge
     February 23, 2011 - October 30, 2010 Evaluation of critical incidents in general surgery. … October 17, 2012 Perioperative patient safety: correct patient, correct surgery, correct … October 20, 2010 Incidence, patterns, and prevention of wrong-site surgery. … 2008 View More See More About The Topic Operating Room Physicians Surgery

447. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44104/psn-pdf
     July 16, 2015 - Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the … Errors upstream and downstream to the Universal Protocol associated with wrong surgery events in the … This analysis of the Veterans Health Administration root cause analysis database found that wrong surgery … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov … /issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

448. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41067/psn-pdf
     February 10, 2012 - Determining the safety of office-based surgery: what 10 years of Florida data and 6 years of Alabama … Determining the safety of office-based surgery: what 10 years of Florida data and 6 years of Alabama … https://psnet.ahrq.gov/issue/determining-safety-office-based-surgery-what-10-years-florida-data-and-6 … - years-alabama-data Concern has been raised about the safety of procedures in ambulatory surgery, … https://psnet.ahrq.gov/issue/office-surgery-incidents-what-seven-years-florida-data-show-us

449. 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

450. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46540/psn-pdf
     August 08, 2018 - Preventing adverse events in cataract surgery: recommendations from a Massachusetts expert panel. … Preventing Adverse Events in Cataract Surgery: Recommendations From a Massachusetts Expert Panel. … https://psnet.ahrq.gov/issue/preventing-adverse-events-cataract-surgery-recommendations- massachusetts-expert-panel … In 2016, five patients undergoing routine cataract surgery developed irreversible visual loss during … in this study use a systems approach to delineate best practices for improving safety of cataract surgery

451. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43408/psn-pdf
     May 01, 2015 - The "weekend effect" in pediatric surgery—increased mortality for children undergoing urgent surgery … The "weekend effect" in pediatric surgery - increased mortality for children undergoing urgent surgery … https://psnet.ahrq.gov/issue/weekend-effect-pediatric-surgery-increased-mortality-children-undergoing … https://psnet.ahrq.gov/issue/weekend-effect-pediatric-surgery-increased-mortality-children-undergoing-urgent-surgery … https://psnet.ahrq.gov/issue/weekend-effect-pediatric-surgery-increased-mortality-children-undergoing-urgent-surgery

452. 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.

453. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45415/psn-pdf
     June 25, 2018 - Association of overlapping surgery with patient outcomes in a large series of neurosurgical cases. … Association of Overlapping Surgery With Patient Outcomes in a Large Series of Neurosurgical Cases. … https://psnet.ahrq.gov/issue/association-overlapping-surgery-patient-outcomes-large-series-neurosurgical … - cases Overlapping surgery refers to the practice of surgeons scheduling two procedures performed … These findings suggest that overlapping surgery can be conducted safely.

454. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46274/psn-pdf
     September 13, 2017 - Wrong-site surgery in California, 2007–2014. … Wrong-site surgery in California, 2007-2014. … Orthopedic surgery accounted for 35% of the cases reported. … https://psnet.ahrq.gov/issue/wrong-site-surgery-california-2007-2014 https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery … /issue/high-reliability-care-orthopedic-surgery-are-we-there-yet

455. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38332/psn-pdf
     January 14, 2009 - Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback … Verifying patient identity and site of surgery: improving compliance with protocol by audit and feedback … https://psnet.ahrq.gov/issue/verifying-patient-identity-and-site-surgery-improving-compliance-protocol-audit … increase compliance with patient identification in the prevention of wrong-patient and wrong-site surgery … related commentary [see link below] discusses the broader context of efforts to eliminate wrong-site surgery

456. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39747/psn-pdf
     August 11, 2010 - Wrong-site sinus surgery in otolaryngology. … Wrong-site sinus surgery in otolaryngology. … found that many respondents had personal experience with wrong-site surgery. … https://psnet.ahrq.gov/issue/wrong-site-sinus-surgery-otolaryngology https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

457. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40714/psn-pdf
     October 04, 2011 - Outcome of 6 years of protocol use for preventing wrong site office surgery. … Outcome of 6 years of protocol use for preventing wrong site office surgery. … https://psnet.ahrq.gov/issue/outcome-6-years-protocol-use-preventing-wrong-site-office-surgery This … study describes the use of a tool to prevent wrong site procedures in a dermatologic surgery setting. … /detecting-adverse-events-dermatologic-surgery

458. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43796/psn-pdf
     June 02, 2015 - Embedding quality and safety in otolaryngology–head and neck surgery education. … Embedding quality and safety in otolaryngology-head and neck surgery education. … https://psnet.ahrq.gov/issue/embedding-quality-and-safety-otolaryngology-head-and-neck-surgery- education … https://psnet.ahrq.gov/issue/embedding-quality-and-safety-otolaryngology-head-and-neck-surgery-education … psnet.ahrq.gov/issue/understanding-patient-safety-third-edition https://psnet.ahrq.gov/issue/wrong-site-surgery-otolaryngology-head-and-neck-surgery

459. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38892/psn-pdf
     August 26, 2009 - Wrong site surgery near misses and actual occurrences. … Wrong site surgery near misses and actual occurrences. … https://psnet.ahrq.gov/issue/wrong-site-surgery-near-misses-and-actual-occurrences This analysis of … wrong-site surgery cases and near misses reported to the Pennsylvania Patient Safety Authority found … /issue/incidence-patterns-and-prevention-wrong-site-surgery https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-surgery

460. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43593/psn-pdf
     May 06, 2015 - Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming … https://psnet.ahrq.gov/issue/reducing-risks-wrong-site-surgery-safety-practices-joint-commission-center … - transforming Wrong-site surgery is a never event, but still occurs at alarming rates. … This report discusses risks related to wrong-site surgery, along with their root causes, and describes … https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery https://psnet.ahrq.gov