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psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation
January 02, 2011 - Multi-use Website
Anesthesia Patient Safety Foundation.
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Anesthesia Patient Safety Foundation. P.O. Box 6668, Rochester, MN 55903.
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psnet.ahrq.gov/issue/implementing-aorn-recommended-practices-laser-safety
July 16, 2018 - Commentary
Implementing AORN recommended practices for laser safety.
Citation Text:
Castelluccio D, Nurses A of OR. Implementing AORN Recommended Practices for Laser Safety. AORN J. 2012;95(5):612-24; quiz 625-7. doi:10.1016/j.aorn.2012.03.001.
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psnet.ahrq.gov/issue/developing-team-cognition-role-simulation
November 01, 2017 - Review
Developing team cognition: a role for simulation.
Citation Text:
Fernandez R, Shah S, Rosenman ED, et al. Developing Team Cognition. Simul Healthc. 2017;12(2):96-103. doi:10.1097/sih.0000000000000200.
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psnet.ahrq.gov/issue/teamwork-and-error-operating-room-analysis-skills-and-roles
April 15, 2009 - Study
Teamwork and error in the operating room: analysis of skills and roles.
Citation Text:
Catchpole K, Mishra A, Handa A, et al. Teamwork and error in the operating room: analysis of skills and roles. Ann Surg. 2008;247(4):699-706. doi:10.1097/SLA.0b013e3181642ec8.
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psnet.ahrq.gov/issue/beyond-organisational-accident-need-error-wisdom-frontline
November 18, 2015 - Commentary
Beyond the organisational accident: the need for "error wisdom" on the frontline.
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Reason J. Beyond the organisational accident: the need for "error wisdom" on the frontline. Qual Saf Health Care. 2004;13 Suppl 2:ii28-33.
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psnet.ahrq.gov/issue/recommendations-quality-assurance-and-improvement-surgical-and-autopsy-pathology
September 29, 2010 - Commentary
Recommendations for quality assurance and improvement in surgical and autopsy pathology.
Citation Text:
Pathology A of D of A and S, Nakhleh RE, Coffin C, et al. Recommendations for quality assurance and improvement in surgical and autopsy pathology. Hum Pathol. 2006;37(8):9…
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psnet.ahrq.gov/issue/critical-diagnoses-critical-values-anatomic-pathology
September 29, 2010 - Commentary
Critical diagnoses (critical values) in anatomic pathology.
Citation Text:
Pathology A of D of A and S, Silverman JF, Fletcher CDM, et al. Critical diagnoses (critical values) in anatomic pathology. Hum Pathol. 2006;37(8):982-4.
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psnet.ahrq.gov/issue/disclosing-unanticipated-outcomes-patients-art-and-practice
July 14, 2010 - Commentary
Disclosing unanticipated outcomes to patients: the art and practice.
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Disclosing unanticipated outcomes to patients: the art and practice. Gallagher TH; Denham CR; Leape LL; Amori G; Levinson W.
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psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005-what-you-need-know
December 17, 2014 - Commentary
Patient Safety and Quality Improvement Act of 2005: what you need to know.
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Rohrich RJ. Patient Safety and Quality Improvement Act of 2005: what you need to know. Plast Reconstr Surg. 2006;117(2):671-2.
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psnet.ahrq.gov/node/33703/psn-pdf
November 01, 2010 - Are We Getting Better at Measuring Patient Safety?
November 1, 2010
Rosen AK. Are We Getting Better at Measuring Patient Safety? PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
Perspective
The past decade has witnessed unprecedented interest in patient safe…
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psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - Hyperglycemia and Switching to Subcutaneous Insulin
Citation Text:
Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/harm-alarm-fatigue
February 14, 2018 - SPOTLIGHT CASE
Harm From Alarm Fatigue
Citation Text:
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/issue/cognitive-forcing-tool-mitigate-cognitive-bias-randomised-control-trial
November 07, 2018 - Study
A cognitive forcing tool to mitigate cognitive bias—a randomised control trial.
Citation Text:
O'Sullivan ED, Schofield SJ. A cognitive forcing tool to mitigate cognitive bias - a randomised control trial. BMC Med Educ. 2019;19(1):12. doi:10.1186/s12909-018-1444-3.
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psnet.ahrq.gov/issue/responding-large-scale-testing-errors
December 18, 2008 - Commentary
Responding to large-scale testing errors.
Citation Text:
Valenstein PN, Alpern GA, Keren DF. Responding to Large-Scale Testing Errors: Table 1. Am J Clin Pathol. 2010;133(3). doi:10.1309/ajcpxlze0yynid0x.
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psnet.ahrq.gov/issue/latency-ecg-displays-hospital-telemetry-systems-science-advisory-american-heart-association
March 14, 2018 - Commentary
Latency of ECG displays of hospital telemetry systems: a science advisory from the American Heart Association.
Citation Text:
Turakhia MP, Estes NAM, Drew BJ, et al. Latency of ECG displays of hospital telemetry systems: a science advisory from the American Heart Association.…
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psnet.ahrq.gov/issue/preventing-medication-errors-community-pharmacy-root-cause-analysis-transcription-errors
March 24, 2011 - Study
Preventing medication errors in community pharmacy: root-cause analysis of transcription errors.
Citation Text:
Knudsen P, Herborg H, Mortensen AR, et al. Preventing medication errors in community pharmacy: root-cause analysis of transcription errors. Qual Saf Health Care. 2007;1…
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psnet.ahrq.gov/issue/development-rating-system-surgeons-non-technical-skills
June 12, 2008 - Study
Development of a rating system for surgeons' non-technical skills.
Citation Text:
Yule S, Flin R, Paterson-Brown S, et al. Development of a rating system for surgeons' non-technical skills. Med Educ. 2006;40(11):1098-104.
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psnet.ahrq.gov/issue/going-solid-model-system-dynamics-and-consequences-patient-safety
August 01, 2018 - Commentary
Classic
"Going solid": a model of system dynamics and consequences for patient safety.
Citation Text:
Cook R, Rasmussen J. "Going solid": a model of system dynamics and consequences for patient safety. Qual Saf Health Care. 2005;14(2):130-4.
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psnet.ahrq.gov/issue/excuse-me-teaching-interns-speak
January 18, 2013 - Study
"Excuse me": teaching interns to speak up.
Citation Text:
O'Connor P, Byrne D, O'Dea A, et al. "Excuse me:" teaching interns to speak up. Jt Comm J Qual Patient Saf. 2013;39(9):426-431.
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psnet.ahrq.gov/issue/managing-clinical-failure-complex-adaptive-system-perspective
August 13, 2014 - Study
Managing clinical failure: a complex adaptive system perspective.
Citation Text:
Matthews JI, Thomas PT. Managing clinical failure: a complex adaptive system perspective. Int J Health Care Qual Assur. 2007;20(3):184-194. doi:10.1108/09526860710743336.
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