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psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - significant downside to pursuing zero harm, argues surgeon Thomas Aloia when considering zero harm goals in surgery … contribute to the high rates of burnout that correspond temporally with an increased emphasis on safety in surgery
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psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
September 01, 2006 - increasing disclosure of adverse events; root cause analyses; and programs for preventing falls, wrong-site surgery … Application of the aviation black box principle in pediatric cardiac surgery: tracking all failures in
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psnet.ahrq.gov/node/848124/psn-pdf
April 26, 2023 - For example,
as an anesthesiologist, during surgery, even if the patient’s blood pressure had gone down … because they’re intensely
focused on performing the surgery.
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psnet.ahrq.gov/node/60721/psn-pdf
July 21, 2020 - The same is true for
certain conditions that are being followed from either surgery or medical specialties … https://www.telehealthresourcecenter.org/
https://www.telehealthresourcecenter.org/
Department of Surgery
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psnet.ahrq.gov/issue/preventing-workplace-violence
July 25, 2023 - July 17, 2013
SOPS Ambulatory Surgery Center Survey: What You Need to Know.
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psnet.ahrq.gov/issue/optimizing-medication-reconciliation-and-transitions-care-insights-pharmacist-and-pharmacy
July 25, 2023 - July 18, 2018
Introducing the AHRQ Ambulatory Surgery Center Survey on Patient Safety
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psnet.ahrq.gov/issue/diagnostic-error-medicine-16th-international-conference
October 12, 2018 - February 5, 2020
A contemporary analysis of closed claims related to wrong site surgery
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psnet.ahrq.gov/issue/mandatory-error-reporting-discourages-disclosure-information
October 26, 2011 - August 11, 2010
Lax oversight leaves surgery center regulators and patients in the dark
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psnet.ahrq.gov/node/49532/psn-pdf
March 15, 2007 - inappropriate
or misapplied in this situation.(3)
Metabolic stressors such as myocardial ischemia, surgery
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psnet.ahrq.gov/node/33564/psn-pdf
March 15, 2025 - failing to order prophylaxis against deep venous thrombosis in a patient who
underwent joint replacement surgery
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psnet.ahrq.gov/node/49463/psn-pdf
October 14, 2004 - Strategies to avoid wrong-site surgery. In: Shojania KG, Duncan BW, McDonald
KM, Wachter RM, eds.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
May 01, 2012 - She was emergently transferred to surgery for removal of the VP shunt and placement of ventricular drain
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Health Care Providers
Health Care Executives and Administrators
Organizational Behaviorists
Surgery
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psnet.ahrq.gov/node/853774/psn-pdf
September 27, 2023 - Utter, MD, MSc
Consulting Editor, AHRQ’s Patient Safety Network (PSNet)
Professor
Department of Surgery … Division of Trauma, Acute Care Surgery, and Surgical Critical Care
UC Davis Health
ghutter@ucdavis.edu
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psnet.ahrq.gov/issue/promoting-patient-safety-one-companys-example
April 05, 2017 - May 16, 2018
Comparison of internal medicine and general surgery residents' assessments
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psnet.ahrq.gov/issue/risk-propensity-and-safe-medication-administration
December 08, 2010 - 2012
Investigating workplace support and the importance of psychological safety in general … surgery residency training.
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psnet.ahrq.gov/issue/medication-administration-errors-and-pediatric-population-systematic-search-literature
September 16, 2015 - 2012
Investigating workplace support and the importance of psychological safety in general … surgery residency training.
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psnet.ahrq.gov/issue/impact-transitioning-24-hour-16-hour-call-model-amongst-cohort-canadian-anesthesia-residents
June 03, 2020 - October 28, 2020
Readiness of US general surgery residents for independent practice.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
January 01, 2020 - Case: ʺReflexiveʺ Diagnosis (3)
Unfortunately, likely due to the delay in making the diagnosis and surgery
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psnet.ahrq.gov/node/49740/psn-pdf
August 21, 2015 - furrowed brow, bunny lines over nasal dorsum,
chin dimpling, lines around corner of mouth
Vascular surgery