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psnet.ahrq.gov/node/33690/psn-pdf
December 01, 2009 - GH: The process begins by making the peer aware, letting them know there will be follow-up. … unusual pattern of problematic behaviors,
how many of them will be remediated simply through being made aware
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - —In this case, the PICU physician was apparently not aware of the competence of the assisting nurse, … nor was he aware of the status of the drugs that had been "ordered" until after the infant desaturated
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psnet.ahrq.gov/node/837041/psn-pdf
May 04, 2022 - APSF endorsed statement on revising recommendations
for patient monitoring during anesthesia.
May 4, 2022
The APSF Committee on Technology. APSF Newsletter. 2022;37(1):7–8.
https://psnet.ahrq.gov/issue/apsf-endorsed-statement-revising-recommendations-patient-monitoring-during-
anesthesia
Variation across sta…
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psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
November 01, 2016 - Describe one simple strategy to ensure primary care providers are aware of in-hospital deaths. … Most likely, the family member who found her and the EMTs who responded were not aware of this patient's … One study found that only 3 in 4 PCPs were aware that their patient had been hospitalized.( 25 ) A more
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psnet.ahrq.gov/issue/monitoring-anaesthetist-operating-theatre-professional-competence-and-patient-safety
November 15, 2023 - Review
Monitoring the anaesthetist in the operating theatre—professional competence and patient safety.
Citation Text:
Larsson J. Monitoring the anaesthetist in the operating theatre - professional competence and patient safety. Anaesthesia. 2017;72 Suppl 1:76-83. doi:10.1111/anae.13743.…
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psnet.ahrq.gov/node/73696/psn-pdf
September 15, 2021 - Factors related to serious safety events in a children's
hospital patient safety collaborative.
September 15, 2021
Burrus S, Hall M, Tooley E, et al. Factors related to serious safety events in a children's hospital patient
safety collaborative. Pediatrics. 2021;148(3):e2020030346. doi:10.1542/peds.2020-030346.
ht…
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psnet.ahrq.gov/issue/incidence-and-or-team-awareness-near-miss-and-retained-surgical-sharps-national-survey-united
December 02, 2020 - Study
Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United States operating rooms.
Citation Text:
Weprin SA, Meyer D, Li R, et al. Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United …
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - —In this case, the PICU physician was apparently not aware of the
competence of the assisting nurse, … nor was he aware of the status of the drugs that had been "ordered"
until after the infant desaturated
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psnet.ahrq.gov/issue/observational-study-direct-oral-anticoagulant-awareness-indicating-inadequate-recognition
April 24, 2018 - Study
An observational study of direct oral anticoagulant awareness indicating inadequate recognition with potential for patient harm.
Citation Text:
Olaiya A, Lurie B, Watt B, et al. An observational study of direct oral anticoagulant awareness indicating inadequate recognition with pot…
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psnet.ahrq.gov/issue/lack-awareness-community-acquired-adverse-drug-reactions-upon-hospital-admission-dimensions
October 16, 2013 - Study
Lack of awareness of community-acquired adverse drug reactions upon hospital admission: dimensions and consequences of a dilemma.
Citation Text:
Dormann H, Criegee-Rieck M, Neubert A, et al. Lack of awareness of community-acquired adverse drug reactions upon hospital admission : …
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psnet.ahrq.gov/issue/using-multidisciplinary-rounds-improve-patient-safety-through-venous-thromboembolism
April 20, 2016 - Study
Using multidisciplinary rounds to improve patient safety through venous thromboembolism prevention awareness.
Citation Text:
Karasin B, Maund C. Using Multidisciplinary Rounds to Improve Patient Safety Through Venous Thromboembolism Prevention Awareness. Jt Comm J Qual Patient Saf.…
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psnet.ahrq.gov/node/47568/psn-pdf
March 06, 2019 - Trends in anesthesia-related liability and lessons learned.
March 6, 2019
Mora JC, Kaye AD, Romankowski ML, et al. Trends in Anesthesia-Related Liability and Lessons Learned.
Adv Anesth. 2018;36(1):231-249. doi:10.1016/j.aan.2018.07.009.
https://psnet.ahrq.gov/issue/trends-anesthesia-related-liability-and-lessons-l…
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psnet.ahrq.gov/node/850170/psn-pdf
June 07, 2023 - A scoping review of distributed cognition in acute care
clinical decision-making.
June 7, 2023
Wilson E, Daniel M, Rao A, et al. A scoping review of distributed cognition in acute care clinical decision-
making. Diagnosis (Berl). 2023;10(2):68-88. doi:10.1515/dx-2022-0095.
https://psnet.ahrq.gov/issue/scoping-revi…
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psnet.ahrq.gov/node/73587/psn-pdf
August 11, 2021 - Effects of a brief team training program on surgical
teams' nontechnical skills: an interrupted time-series
study.
August 11, 2021
Gillespie BM, Harbeck EL, Kang E, et al. Effects of a brief team training program on surgical teams'
nontechnical skills: an interrupted time-series study. J Patient Saf. 2021;17(5):e4…
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psnet.ahrq.gov/node/836715/psn-pdf
March 09, 2022 - Non-technical skills in surgery during the COVID-19
pandemic: an observational study.
March 9, 2022
Etheridge JC, Moyal-Smith R, Sonnay Y, et al. Non-technical skills in surgery during the COVID-19
pandemic: an observational study. Int J Surg. 2022;98:106210. doi:10.1016/j.ijsu.2021.106210.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/74127/psn-pdf
December 01, 2021 - Effectiveness of using simulation in the development of
clinical reasoning in undergraduate nursing students: a
systematic review.
December 1, 2021
Theobald KA, Tutticci N, Ramsbotham J, et al. Effectiveness of using simulation in the development of
clinical reasoning in undergraduate nursing students: a systemati…
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psnet.ahrq.gov/issue/application-surgical-safety-standards-robotic-surgery-five-principles-ethics-nonmaleficence
October 19, 2022 - Review
Application of surgical safety standards to robotic surgery: five principles of ethics for nonmaleficence.
Citation Text:
Larson JA, Johnson MH, Bhayani SB. Application of surgical safety standards to robotic surgery: five principles of ethics for nonmaleficence. J Am Coll Surg. …
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psnet.ahrq.gov/issue/use-common-gas-outlet-supplementary-oxygen-during-caesarean-section
August 04, 2021 - Commentary
Use of the common gas outlet for supplementary oxygen during Caesarean section.
Citation Text:
Edsell MEG, Erasmus PD. Use of the common gas outlet for supplementary oxygen during Caesarean section. Anaesthesia. 2005;60(11):1152-3.
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psnet.ahrq.gov/issue/no-simple-fix-fixation-errors-cognitive-processes-and-their-clinical-applications
February 10, 2012 - Study
No simple fix for fixation errors: cognitive processes and their clinical applications.
Citation Text:
Fioratou E, Flin R, Glavin R. No simple fix for fixation errors: cognitive processes and their clinical applications. Anaesthesia. 2009;65(1). doi:10.1111/j.1365-2044.2009.05994…
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psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
May 16, 2022 - Sarah Mossburg: I'm curious if you're aware of what kind of trends that are being identified with some … front lines and qualitative experiences—we noticed that we're a little bit below our goal, are you all aware … I'm curious if you are aware of any data emerging on prevalence of specific safety events within the … Remle Crowe: I'm not aware of any published; that doesn't mean it doesn't exist because I haven't read … the culture of safety is really becoming something that's a little bit more prevalent and people are aware