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psnet.ahrq.gov/primer/individual-clinician-performance-issues
March 15, 2025 - The health professions educational system aspires to train clinicians to achieve basic proficiency in
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psnet.ahrq.gov/issue/quality-and-safety-pediatric-anesthesia-how-can-guidelines-checklists-and-initiatives-improve
December 11, 2024 - Review
Quality and safety in pediatric anesthesia: how can guidelines, checklists, and initiatives improve the outcome?
Citation Text:
Hagerman NS, Varughese AM, Kurth D. Quality and safety in pediatric anesthesia: how can guidelines, checklists, and initiatives improve the outcome? Curr…
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psnet.ahrq.gov/issue/do-micropauses-prevent-surgeons-fatigue-and-loss-accuracy-associated-prolonged-surgery
November 29, 2023 - Study
Do micropauses prevent surgeon's fatigue and loss of accuracy associated with prolonged surgery? An experimental prospective study.
Citation Text:
Dorion D, Darveau S. Do micropauses prevent surgeon's fatigue and loss of accuracy associated with prolonged surgery? An experimental…
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psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-and-improve-health
February 26, 2025 - significantly greater risk for 30-, 60-, and 90-day hospital readmission. 6 Case management and supports for basic
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psnet.ahrq.gov/issue/decision-making-emergency-medicine-biases-errors-and-solutions
January 20, 2021 - Book/Report
Decision Making in Emergency Medicine: Biases, Errors and Solutions.
Citation Text:
Decision Making in Emergency Medicine: Biases, Errors and Solutions. Raz M, Pouryahya P, eds. Singapore; Springer Nature Singapore Pte Ltd; 2021. ISBN 9789811601422.
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psnet.ahrq.gov/issue/guideline-prevention-retained-surgical-items
April 26, 2023 - Commentary
Guideline for prevention of retained surgical items.
Citation Text:
Putnam K. Guideline for prevention of retained surgical items. AORN J. 2015;102(6):P11-P13.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
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psnet.ahrq.gov/issue/lost-sponge-patient-safety-operating-room
January 26, 2022 - Commentary
The lost sponge: patient safety in the operating room.
Citation Text:
Grant-Orser A, Davies P, Singh SS. The lost sponge: patient safety in the operating room. CMAJ . 2012;184(11):1275-1278. doi:10.1503/cmaj.110900.
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psnet.ahrq.gov/node/855058/psn-pdf
October 31, 2023 - ’s really important to address those issues so that the
environment for care delivery is safe on a basic … Basic patient safety activities, which include promoting teamwork, good
handoffs, timely responses to
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psnet.ahrq.gov/issue/comprehensive-healthcare-inspection-summary-report-evaluation-care-coordination-veterans
July 27, 2022 - Book/Report
Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.
Citation Text:
Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administra…
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psnet.ahrq.gov/issue/accidental-iv-infusion-heparinized-irrigation-or
September 14, 2016 - Newspaper/Magazine Article
Accidental IV infusion of heparinized irrigation in the OR.
Citation Text:
Accidental IV infusion of heparinized irrigation in the OR. ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3.
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psnet.ahrq.gov/issue/unlabeled-containers-lead-patients-death
September 26, 2017 - Commentary
Unlabeled containers lead to patient's death.
Citation Text:
Cohen MR, Smetzer JL. Unlabeled containers lead to patient's death. Jt Comm J Qual Patient Saf. 2005;31(7):414-7.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/issue/strategies-and-tips-maximizing-failure-mode-and-effect-analysis-your-organization
January 13, 2016 - Book/Report
Strategies and tips for maximizing failure mode and effect analysis in your organization.
Citation Text:
Strategies and tips for maximizing failure mode and effect analysis in your organization. Chicago, IL: American Society of Healthcare Risk Management; 2002.
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psnet.ahrq.gov/issue/provider-interruptions-and-patient-perceptions-care-observational-study-emergency-department
June 26, 2024 - Study
Provider interruptions and patient perceptions of care: an observational study in the emergency department.
Citation Text:
Schneider A, Wehler M, Weigl M. Provider interruptions and patient perceptions of care: an observational study in the emergency department. BMJ Qual Saf. 2019;…
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psnet.ahrq.gov/issue/positive-deviance-different-approach-achieving-patient-safety
May 15, 2024 - Commentary
Positive deviance: a different approach to achieving patient safety.
Citation Text:
Lawton R, Taylor N, Clay-Williams R, et al. Positive deviance: a different approach to achieving patient safety. BMJ Qual Saf. 2014;23(11):880-3. doi:10.1136/bmjqs-2014-003115.
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psnet.ahrq.gov/issue/determination-health-care-teamwork-training-competencies-delphi-study
May 15, 2024 - Study
Determination of health-care teamwork training competencies: a Delphi study.
Citation Text:
Clay-Williams R, Braithwaite J. Determination of health-care teamwork training competencies: a Delphi study. Int J Qual Health Care. 2009;21(6):433-40. doi:10.1093/intqhc/mzp042.
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psnet.ahrq.gov/issue/thinking-threes-changing-surgical-patient-safety-practices-complex-modern-operating-room
April 28, 2021 - Commentary
Thinking in three's: changing surgical patient safety practices in the complex modern operating room.
Citation Text:
Gibbs VC. Thinking in three's: changing surgical patient safety practices in the complex modern operating room. World J Gastroenterol. 2012;18(46):6712-9. doi:…
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psnet.ahrq.gov/issue/surgical-complications-disclosing-adverse-events-and-medical-errors
September 23, 2020 - Commentary
Surgical complications: disclosing adverse events and medical errors.
Citation Text:
Wang AS, Eisen DB. Surgical complications: disclosing adverse events and medical errors. J Am Acad Dermatol. 2013;68(1):144-6. doi:10.1016/j.jaad.2012.09.008.
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psnet.ahrq.gov/issue/high-costs-weak-compliance-new-york-state-hospital-adverse-event-reporting-and-tracking
July 22, 2020 - Book/Report
The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System.
Citation Text:
The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System. Thompson WC Jr. New York, NY: Off…
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psnet.ahrq.gov/issue/prevent-errors-during-emergency-use-hypertonic-sodium-chloride-solutions
March 10, 2021 - Newspaper/Magazine Article
Prevent errors during emergency use of hypertonic sodium chloride solutions.
Citation Text:
Prevent errors during emergency use of hypertonic sodium chloride solutions. ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4.
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psnet.ahrq.gov/node/33644/psn-pdf
December 01, 2006 - New York, NY: Basic Books;
1983.
7. Senge PM.