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psnet.ahrq.gov/node/43033/psn-pdf
March 12, 2014 - Current challenges and future perspectives for patient
safety in surgery.
March 12, 2014
Stahel PF, Mauffrey C, Butler N. Current challenges and future perspectives for patient safety in surgery.
Patient Saf Surg. 2014;8(1):9. doi:10.1186/1754-9493-8-9.
https://psnet.ahrq.gov/issue/current-challenges-and-future-pe…
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psnet.ahrq.gov/node/46508/psn-pdf
November 22, 2017 - The checklist: recognize limits, but harness its power.
November 22, 2017
Alspach JAG. The Checklist: Recognize Limits, but Harness Its Power. Crit Care Nurse. 2017;37(5):12-18.
doi:10.4037/ccn2017603.
https://psnet.ahrq.gov/issue/checklist-recognize-limits-harness-its-power
Checklists are used in various health c…
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psnet.ahrq.gov/node/856640/psn-pdf
November 29, 2023 - Research from webAIRS incident reporting system.
November 29, 2023
Anaesth Intensive Care. 2023;51(6):372-421.
https://psnet.ahrq.gov/issue/research-webairs-incident-reporting-system
Centralized de-identified reports of patient safety events serve a core purpose for learning and
improvement. This article collectio…
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psnet.ahrq.gov/node/41849/psn-pdf
December 05, 2012 - Improving care transitions: current practice and future
opportunities for pharmacists.
December 5, 2012
Pharmacy AC of C, Hume AL, Kirwin J, et al. Improving care transitions: current practice and future
opportunities for pharmacists. Pharmacotherapy. 2012;32(11):e326-37. doi:10.1002/phar.1215.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/50825/psn-pdf
January 22, 2020 - Investigation into Detection of Retained Vaginal Swabs
and Tampons Following Childbirth.
January 22, 2020
Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.
https://psnet.ahrq.gov/issue/investigation-detection-retained-vaginal-swabs-and-tampons-following-
childbirth
Maternal care during a…
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psnet.ahrq.gov/node/45837/psn-pdf
March 08, 2017 - Promoting civility in the OR: an ethical imperative.
March 8, 2017
Clark CM, Kenski D. Promoting Civility in the OR: An Ethical Imperative. AORN J. 2017;105(1):60-66.
doi:10.1016/j.aorn.2016.10.019.
https://psnet.ahrq.gov/issue/promoting-civility-or-ethical-imperative
The operating room is a complex environment th…
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psnet.ahrq.gov/node/861295/psn-pdf
January 24, 2024 - Investigators find hospital error caused mother’s death in
Brooklyn.
January 24, 2024
Goldstein J. New York Times. January 14, 2024.
https://psnet.ahrq.gov/issue/investigators-find-hospital-error-caused-mothers-death-brooklyn
Maternal safety is challenged in the Unites States and particularly for minorities. This …
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psnet.ahrq.gov/node/45756/psn-pdf
December 21, 2016 - Accidental IV infusion of heparinized irrigation in the OR.
December 21, 2016
ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3.
https://psnet.ahrq.gov/issue/accidental-iv-infusion-heparinized-irrigation-or
Accidental administration of irrigation solutions are a wrong-route error that can re…
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psnet.ahrq.gov/node/46731/psn-pdf
July 25, 2018 - When bullying affects patient safety.
July 25, 2018
When Bullying Affects Patient Safety. AORN J. 2018;108(1):78-80. doi:10.1002/aorn.12294.
https://psnet.ahrq.gov/issue/when-bullying-affects-patient-safety
Bullying has been recognized as an important factor to consider in health care work environments.
Describing…
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psnet.ahrq.gov/node/47650/psn-pdf
January 30, 2019 - The impact of technology on safe medicines use and
pharmacy practice in the US.
January 30, 2019
Schneider PJ. The Impact of Technology on Safe Medicines Use and Pharmacy Practice in the US. Front
Pharmacol. 2018;9:1361. doi:10.3389/fphar.2018.01361.
https://psnet.ahrq.gov/issue/impact-technology-safe-medicines-us…
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psnet.ahrq.gov/node/72583/psn-pdf
December 16, 2020 - Wear face masks with no metal during MRI exams.
December 16, 2020
FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug
Administration; December 7, 2020.
https://psnet.ahrq.gov/issue/wear-face-masks-no-metal-during-mri-exams
Magnetic resonance imaging (MRI) requires patient prep…
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psnet.ahrq.gov/node/43458/psn-pdf
August 27, 2014 - Validation of a teamwork perceptions measure to increase
patient safety.
August 27, 2014
Keebler JR, Dietz AS, Lazzara EH, et al. Validation of a teamwork perceptions measure to increase patient
safety. BMJ Qual Saf. 2014;23(9):718-26. doi:10.1136/bmjqs-2013-001942.
https://psnet.ahrq.gov/issue/validation-teamwork…
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psnet.ahrq.gov/node/35724/psn-pdf
May 26, 2010 - A prospective study of patient safety in the operating
room.
May 26, 2010
Christian CK, Gustafson ML, Roth EM, et al. A prospective study of patient safety in the operating room.
Surgery. 2006;139(2):159-173.
https://psnet.ahrq.gov/issue/prospective-study-patient-safety-operating-room
This study used a multidisci…
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psnet.ahrq.gov/node/46659/psn-pdf
December 06, 2017 - Focus On: Health Care Policy and Quality.
December 6, 2017
AJR Am J Roentgenol. 2017;209(5):965-1008;w333-w334.
https://psnet.ahrq.gov/issue/focus-health-care-policy-and-quality
Radiologists play a critical role in safe diagnostic imaging and communication of test results. Articles in this
special issue explore cl…
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psnet.ahrq.gov/node/838909/psn-pdf
October 26, 2022 - Designing safety interventions for specific contexts:
results from a literature review.
October 26, 2022
Karanikas N, Khan SR, Baker PRA, et al. Designing safety interventions for specific contexts: Results from
a literature review. Safety Sci. 2022;156:105906. doi:10.1016/j.ssci.2022.105906.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/44816/psn-pdf
June 29, 2016 - Paralyzed by errors, this Xbox designer is taking on
hospital safety.
June 29, 2016
Aleccia J.
https://psnet.ahrq.gov/issue/paralyzed-errors-xbox-designer-taking-hospital-safety
Patients who experience harm while receiving medical care can serve as powerful advocates for patient
safety. This news article reports …
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psnet.ahrq.gov/node/46301/psn-pdf
October 11, 2017 - Care transitions know-how not just for clinicians.
October 11, 2017
Ready T. HealthLeaders Media. September 26, 2017.
https://psnet.ahrq.gov/issue/care-transitions-know-how-not-just-clinicians
Transitions are an error-prone process. This news article reports that organizational leadership should be
engaged in enha…
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psnet.ahrq.gov/node/60163/psn-pdf
March 25, 2020 - Broken, fragmented health-care system failed daughter
who died by suicide.
March 25, 2020
Klowak M. CBC News. March 9, 2020.
https://psnet.ahrq.gov/issue/broken-fragmented-health-care-system-failed-daughter-who-died-suicide
System weaknesses are often at the root of never events. This news story discusses the suic…
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psnet.ahrq.gov/node/43000/psn-pdf
March 05, 2014 - Elective surgical patients' narratives of hospitalization:
the co-construction of safety.
March 5, 2014
DOHERTY CAROLE, Saunders MNK. Elective surgical patients' narratives of hospitalization: the co-
construction of safety. Soc Sci Med. 2013;98:29-36. doi:10.1016/j.socscimed.2013.08.014.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/42504/psn-pdf
August 14, 2014 - The effect of an organizational network for patient safety
on safety event reporting.
August 14, 2014
Jeffs L, Hayes C, Smith O, et al. The effect of an organizational network for patient safety on safety event
reporting. Eval Health Prof. 2014;37(3):366-78. doi:10.1177/0163278713491267.
https://psnet.ahrq.gov/iss…