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561. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46495/psn-pdf
     December 13, 2017 - Wrong-site surgery. December 13, 2017 Engelhardt KE, Barnard C, Bilimoria KY. Wrong-Site Surgery. … https://psnet.ahrq.gov/issue/wrong-site-surgery-1 This commentary describes a case of wrong-site surgery … https://psnet.ahrq.gov/issue/wrong-site-surgery-1 https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery

562. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42591/psn-pdf
     July 16, 2015 - Underreporting of robotic surgery complications. … Underreporting of robotic surgery complications. … https://psnet.ahrq.gov/issue/underreporting-robotic-surgery-complications By cross-referencing court … A checklist has been proposed to minimize hazards in robotic surgery. … https://psnet.ahrq.gov/issue/underreporting-robotic-surgery-complications https://psnet.ahrq.gov/issue

563. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44264/psn-pdf
     May 03, 2016 - Introducing the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture. … https://psnet.ahrq.gov/issue/introducing-ahrq-ambulatory-surgery-center-survey-patient-safety-culture … Ambulatory surgery centers have been the focus of patient safety concerns due to high-profile incidents … Survey, results of its pilot test, and insights from ambulatory surgery centers using the survey. … https://psnet.ahrq.gov/issue/introducing-ahrq-ambulatory-surgery-center-survey-patient-safety-culture

564. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40489/psn-pdf
     June 01, 2011 - Handover after pediatric heart surgery: a simple tool improves information exchange. … Handover after pediatric heart surgery: a simple tool improves information exchange. … https://psnet.ahrq.gov/issue/handover-after-pediatric-heart-surgery-simple-tool-improves-information- … exchange Use of a structured tool improved the quality of handoffs for postoperative pediatric cardiac surgery … https://psnet.ahrq.gov/issue/handover-after-pediatric-heart-surgery-simple-tool-improves-information-exchange

565. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38846/psn-pdf
     August 05, 2009 - Seeking a safer surgery: some states crack down on doctors who perform unregulated outpatient procedures … https://psnet.ahrq.gov/issue/seeking-safer-surgery-some-states-crack-down-doctors-who-perform- unregulated-outpatient … This article discusses growing legal oversight on outpatient surgery performed in physicians' offices … https://psnet.ahrq.gov/issue/seeking-safer-surgery-some-states-crack-down-doctors-who-perform-unregulated-outpatient … https://psnet.ahrq.gov/issue/office-surgery-incidents-what-seven-years-florida-data-show-us

566. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.33_slideshow.ppt
     October 01, 2003 - this educational activity, participants should be able to: List factors contributing to wrong site surgery … Case (cont.): Wrong Side Surgery The next day, the Chief of Pathology called the trainee to inquire … Wrong Side Surgery: Scope of the Problem JCAHO: 114 wrong site surgeries from 1152 sentinel events ( … Incidence of wrong-site surgery among hand surgeons. … Ensuring correct surgery; 2002.

567. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36430/psn-pdf
     March 28, 2011 - Experience of wrong site surgery and surgical marking practices among clinicians in the UK. … Experience of wrong site surgery and surgical marking practices among clinicians in the UK. … https://psnet.ahrq.gov/issue/experience-wrong-site-surgery-and-surgical-marking-practices-among- clinicians-uk … The investigators analyzed incidents of wrong-site surgery and surgical marking practices in the United … https://psnet.ahrq.gov/issue/experience-wrong-site-surgery-and-surgical-marking-practices-among-clinicians-uk

568. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35584/psn-pdf
     April 06, 2011 - Discrepancies between surgery and anesthesiology preoperative medication histories. … Discrepancies between surgery and anesthesiology preoperative medication histories. … https://psnet.ahrq.gov/issue/what-patient-really-taking-discrepancies-between-surgery-and-anesthesiology … compared postoperative intensive care unit admission records at one hospital to track differences between surgery … https://psnet.ahrq.gov/issue/what-patient-really-taking-discrepancies-between-surgery-and-anesthesiology-preoperative

569. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37074/psn-pdf
     October 03, 2011 - Perioperative patient safety: correct patient, correct surgery, correct side--a multifaceted, cross- … Perioperative patient safety: correct patient, correct surgery, correct side--a multifaceted, cross-organizational … https://psnet.ahrq.gov/issue/perioperative-patient-safety-correct-patient-correct-surgery-correct-side … multifaceted-cross In this study, a formal checklist was implemented to ensure appropriate patient preparation for surgery … https://psnet.ahrq.gov/issue/perioperative-patient-safety-correct-patient-correct-surgery-correct-side-multifaceted-cross

570. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46076/psn-pdf
     September 24, 2017 - The evolving story of overlapping surgery. September 24, 2017 Mello MM, Livingston EH. … The Evolving Story of Overlapping Surgery. JAMA. 2017;318(3):233-234. doi:10.1001/jama.2017.8061. … https://psnet.ahrq.gov/issue/evolving-story-overlapping-surgery Scheduling overlapping procedures is … https://psnet.ahrq.gov/issue/evolving-story-overlapping-surgery https://psnet.ahrq.gov/issue/clash-name-care … https://psnet.ahrq.gov/issue/safety-overlapping-surgery-high-volume-referral-center https://psnet.ahrq.gov

571. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44752/psn-pdf
     April 20, 2016 - Nontechnical skills in pediatric surgery: factors influencing operative performance. … Nontechnical skills in pediatric surgery: Factors influencing operative performance. … https://psnet.ahrq.gov/issue/nontechnical-skills-pediatric-surgery-factors-influencing-operative-performance … training, and assessing surgeon competencies in a defined set of nontechnical skills during pediatric surgery … https://psnet.ahrq.gov/issue/nontechnical-skills-pediatric-surgery-factors-influencing-operative-performance

572. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40490/psn-pdf
     June 01, 2011 - Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive … Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive … https://psnet.ahrq.gov/issue/standardized-multidisciplinary-protocol-improves-handover-cardiac-surgery … handoff system reduced technical errors and improved the quality of handoffs when transferring cardiac surgery … https://psnet.ahrq.gov/issue/standardized-multidisciplinary-protocol-improves-handover-cardiac-surgery-patients-intensive

573. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33953/psn-pdf
     February 05, 2018 - Evidence-based Recommendations for Best Practices in Weight Loss Surgery.  … February 5, 2018 Expert Panel on Weight Loss Surgery, Betsy Lehman Center for Patient Safety and Medical … https://psnet.ahrq.gov/issue/expert-panel-weight-loss-surgery-betsy-lehman-center-patient-safety-and- … https://psnet.ahrq.gov/issue/expert-panel-weight-loss-surgery-betsy-lehman-center-patient-safety-and-medical-error … https://psnet.ahrq.gov/issue/safety-culture-and-complications-after-bariatric-surgery

574. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39047/psn-pdf
     October 28, 2009 - ProvenCare: quality improvement model for designing highly reliable care in cardiac surgery. … ProvenCare: quality improvement model for designing highly reliable care in cardiac surgery. … /psnet.ahrq.gov/issue/provencare-quality-improvement-model-designing-highly-reliable-care-cardiac- surgery … ://psnet.ahrq.gov/issue/provencare-quality-improvement-model-designing-highly-reliable-care-cardiac-surgery … ://psnet.ahrq.gov/issue/provencare-quality-improvement-model-designing-highly-reliable-care-cardiac-surgery

575. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42774/psn-pdf
     May 28, 2015 - Patient safety in plastic surgery: identifying areas for quality improvement efforts. … Patient safety in plastic surgery: identifying areas for quality improvement efforts. … https://psnet.ahrq.gov/issue/patient-safety-plastic-surgery-identifying-areas-quality-improvement-efforts … Using AHRQ patient safety indicators, this study established that approximately 4% of plastic surgery … https://psnet.ahrq.gov/issue/patient-safety-plastic-surgery-identifying-areas-quality-improvement-efforts

576. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38541/psn-pdf
     May 21, 2009 - The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level … The relationship between inpatient cardiac surgery mortality and nurse numbers and educational level … https://psnet.ahrq.gov/issue/relationship-between-inpatient-cardiac-surgery-mortality-and-nurse-numbers … general wards—but not in the intensive care unit—was associated with reduced mortality for cardiac surgery … https://psnet.ahrq.gov/issue/relationship-between-inpatient-cardiac-surgery-mortality-and-nurse-numbers-and-educational

577. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39983/psn-pdf
     December 06, 2010 - Patient safety during anaesthesia: incorporation of the WHO safe surgery guidelines into clinical practice … Patient safety during anaesthesia: incorporation of the WHO safe surgery guidelines into clinical practice … https://psnet.ahrq.gov/issue/patient-safety-during-anaesthesia-incorporation-who-safe-surgery-guidelines … https://psnet.ahrq.gov/issue/patient-safety-during-anaesthesia-incorporation-who-safe-surgery-guidelines-clinical-practice … https://psnet.ahrq.gov/issue/safe-surgery-saves-lives-second-global-patient-safety-challenge

578. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42677/psn-pdf
     July 16, 2015 - Using "near misses" analysis to prevent wrong-site surgery. … Using "near misses" analysis to prevent wrong-site surgery. … https://psnet.ahrq.gov/issue/using-near-misses-analysis-prevent-wrong-site-surgery By tracking improper … surgical bookings and observing time-out procedures, this study measured near misses for wrong-site surgery … https://psnet.ahrq.gov/issue/using-near-misses-analysis-prevent-wrong-site-surgery https://psnet.ahrq.gov

579. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49537/psn-pdf
     June 01, 2007 - Appreciate the importance of communication and collaboration between providers before surgery. … Preoperatively, the patient was evaluated by both the anesthesiology and surgery teams. … Given the prior AAA repair, the patient underwent surgery in the supine position. … This assessment must appreciate the reality that surgery is a morbid event. … Communication and collaboration among providers before surgery are critical.

580. Reused devices, surgery's deadly suspects. | PSNet
     psnet.ahrq.gov/issue/reused-devices-surgerys-deadly-suspects
     January 04, 2006 - April 2, 2014 When surgery goes wrong: weighing up the risks.