Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
PSNet Original Content
1 - 10 of 10
Kremer MJ, Hirsch M, Geisz-Everson M, et al. AANA J. 2019;87.
This thematic analysis identified 123 events comprising malpractice claims in the closed claims database of the American Association of Nurse Anesthetists (AANA) Foundation that the investigators determined could have been prevented by the Certified Registered Nurse Anesthetist involved. Among the factors identified as being associated with preventable events were communication failures, violations of the AANA Standards for Nurse Anesthesia Practice, and errors in judgment.
DeRosier JM, Hansemann BK, Smith-Wheelock MW, et al. Jt Comm J Qual Patient Saf. 2019;45:680-685.
Researchers used failure mode and effects analysis to examine intraocular lens implantation. They report uncovering many potential failure modes or safety vulnerabilities and extensive variation in how this procedure is conducted. The authors recommend standardization, changes to equipment and workflows, and quality assurance through direct observation in order to enhance safety.

Todd DW, Bennett JD, eds. Oral Maxillofac Surg Clin North Am. 2017;29:121-244.

Articles in this special issue provide insights into how human error can affect the safety of oral and maxillofacial surgery, a primarily ambulatory environment. The authors cover topics such as simulation training, wrong-site surgery, and the safety of office-based anesthesia.
Rockville, MD: Agency for Healthcare Research and Quality; December 2014.
Ambulatory surgery centers provide care to growing numbers of patients. This toolkit draws from AHRQ's Comprehensive Unit-based Safety Program to help ambulatory surgical center teams develop communication and teamwork skills to reduce infections and other iatrogenic harms.
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
Ambulatory surgery centers are increasingly being used to provide surgical care. The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center Survey seeks opinions from the field regarding safety culture in the ambulatory surgical center environment. The survey is presented with additional resources to help organizations assess their safety culture, including the results of a pilot program testing the survey and a user's guide.
American College of Surgeons.
This Web site offers resources for both practitioners and patients to optimize safety through pre-procedure planning.
Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-8.
Wrong-site surgeries are considered rare but devastating never events. However, a recent article suggested that wrong-site procedures may be more common than previously thought, since such errors can occur in procedures performed in areas other than the operating room. This study sought to evaluate the incidence of wrong-site surgery in pain management, using data from 10 facilities over a 2-year period. Although the overall incidence was low—only 13 cases were found with minimal associated patient harm—most cases were considered preventable, as clinicians failed to follow recommended preventive measures. A wrong-site surgery near miss is discussed in this AHRQ WebM&M commentary.