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psnet.ahrq.gov/issue/inadequate-hand-communication
April 02, 2015 - Sentinel Event Alerts
Inadequate hand-off communication.
Citation Text:
Inadequate hand-off communication. Sentinel event alert. 2017;58(58):1-6.
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psnet.ahrq.gov/issue/implementation-surgical-safety-checklist-and-postoperative-outcomes-prospective-randomized
October 10, 2018 - Study
Implementation of a surgical safety checklist and postoperative outcomes: a prospective randomized controlled study.
Citation Text:
Chaudhary N, Varma V, Kapoor S, et al. Implementation of a surgical safety checklist and postoperative outcomes: a prospective randomized controlled s…
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psnet.ahrq.gov/issue/review-alternatives-root-cause-analysis-developing-robust-system-incident-report-analysis
November 14, 2018 - Review
Review of alternatives to root cause analysis: developing a robust system for incident report analysis.
Citation Text:
Hagley G, Mills PD, Watts B, et al. Review of alternatives to root cause analysis: developing a robust system for incident report analysis. BMJ Open Qual. 2019;8(…
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psnet.ahrq.gov/issue/medical-errors-and-consequent-adverse-events-critically-ill-surgical-patients-tertiary-care
December 22, 2010 - Study
Medical errors and consequent adverse events in critically ill surgical patients in a tertiary care teaching hospital in Delhi.
Citation Text:
Kumar S, Chaudhary S. Medical errors and consequent adverse events in critically ill surgical patients in a tertiary care teaching hospita…
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psnet.ahrq.gov/node/60529/psn-pdf
May 27, 2020 - The role of cognitive bias in breast radiology diagnostic
and judgment errors.
May 27, 2020
Loving VA, Valencia EM, Patel B, et al. The role of cognitive bias in breast radiology diagnostic and
judgment errors. J Breast Imag. 2020. doi:10.1093/jbi/wbaa023.
https://psnet.ahrq.gov/issue/role-cognitive-bias-breast-ra…
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psnet.ahrq.gov/node/72831/psn-pdf
March 10, 2021 - Enhancing a culture of safety through disclosure of
adverse events.
March 10, 2021
Cornelissen C, Call RC, Harbell MW, et al. APSF Newsletter. February 202136(1);25-27
https://psnet.ahrq.gov/issue/enhancing-culture-safety-through-disclosure-adverse-events
Error disclosure is supported by a robust safety …
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psnet.ahrq.gov/node/60944/psn-pdf
September 23, 2020 - Flexibilization of science, cognitive biases, and the
COVID-19 pandemic.
September 23, 2020
Oliveira J. e Silva L, Vidor MV, Zarpellon de Araújo V, et al. Flexibilization of science, cognitive biases, and
the COVID-19 pandemic. Mayo Clin Proc. 2020;95(9):1842-1844. doi:10.1016/j.mayocp.2020.06.037.
https://psnet.a…
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psnet.ahrq.gov/node/843091/psn-pdf
January 25, 2023 - Anesthesia outside of the OR: cause for patient safety
concerns?
January 25, 2023
DePeau-Wilson M. MedPage Today. January 13, 2023.
https://psnet.ahrq.gov/issue/anesthesia-outside-or-cause-patient-safety-concerns
The use of anesthesia in ambulatory settings presents both advantage and risk to patients and clinicia…
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psnet.ahrq.gov/node/33942/psn-pdf
January 14, 2011 - The bell curve.
January 14, 2011
Gawande A. New Yorker. Dec 6, 2004.
https://psnet.ahrq.gov/issue/bell-curve
A sensitive portrayal of the challenges in defining quality and implementing change even when practitioners
are committed to high-quality care.
https://psnet.ahrq.gov/issue/bell-curve
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.359_slideshow.ppt
October 01, 2015 - two key barriers to incorporation and reconciliation of information transmitted between institutions
Define
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psnet.ahrq.gov/node/33840/psn-pdf
August 01, 2017 - transitions and handoffs; ensure that residents and fellows can be relieved of responsibilities
when needed; define
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.179_slideshow.ppt
July 01, 2008 - Objectives
At the conclusion of this educational activity, participants should be able to:
Define
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.338_slideshow.ppt
January 01, 2015 - Credits
2
Objectives
At the conclusion of this educational activity, participants should be able to:
Define
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.158_slideshow.ppt
September 01, 2007 - accounts for many preventable adverse events
To design a robust medication reconciliation process, first define
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psnet.ahrq.gov/node/49757/psn-pdf
April 01, 2016 - Before attempting to define situational awareness for any type of clinical practice, it is first critical
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psnet.ahrq.gov/issue/rate-sepsis-hospitalizations-after-misdiagnosis-adult-emergency-department-patients-look
December 08, 2021 - Study
Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated health system.
Citation Text:
Horberg MA, Nassery …
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psnet.ahrq.gov/node/44934/psn-pdf
February 07, 2023 - National Safety Standards for Invasive Procedures
(NatSSIPs2).
February 7, 2023
Centre for Perioperative Care. London, UK; January 2023.
https://psnet.ahrq.gov/issue/national-safety-standards-invasive-procedures-natssips
Patients face risks when undergoing surgery. This revised guidance provides recommendations de…
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psnet.ahrq.gov/node/851451/psn-pdf
July 19, 2023 - Issues and complexities in safety culture assessment in
healthcare.
July 19, 2023
Ellis LA, Falkland E, Hibbert P, et al. Issues and complexities in safety culture assessment in healthcare.
Front Public Health. 2023;11:1217542. doi:10.3389/fpubh.2023.1217542.
https://psnet.ahrq.gov/issue/issues-and-complexities-sa…
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psnet.ahrq.gov/node/74145/psn-pdf
January 01, 2022 - Diagnostic Excellence in the ICU: Thinking Critically and
Masterfully.
December 1, 2021
Bergl PA, Nanchal RS, eds. Crit Care Clin. 2022;38(1):1-158.
https://psnet.ahrq.gov/issue/diagnostic-excellence-icu-thinking-critically-and-masterfully
Critical care diagnosis is complicated by factors such as stress, patient a…
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psnet.ahrq.gov/node/60569/psn-pdf
June 10, 2020 - Workplace team resilience: a systematic review and
conceptual development.
June 10, 2020
Hartwig A, Clarke S, Johnson S, et al. Workplace team resilience: s systematic review and conceptual
development. Org Psychol Rev. 2020;10(3-4):169-200. doi:10.1177/2041386620919476.
https://psnet.ahrq.gov/issue/workplace-team…