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psnet.ahrq.gov/node/35935/psn-pdf
June 16, 2011 - Operating room teamwork among physicians and nurses:
teamwork in the eye of the beholder.
June 16, 2011
Makary MA, Sexton B, Freischlag JA, et al. Operating room teamwork among physicians and nurses:
teamwork in the eye of the beholder. J Am Coll Surg. 2006;202(5):746-52.
https://psnet.ahrq.gov/issue/operating-roo…
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psnet.ahrq.gov/node/47900/psn-pdf
January 01, 2021 - Is physician mentorship associated with the occurrence
of adverse patient safety events?
April 10, 2019
Harrison R, Sharma A, Lawton R, et al. Is Physician Mentorship Associated With the Occurrence of
Adverse Patient Safety Events? J Patient Saf. 2021;17(8):e1633-e1637.
doi:10.1097/PTS.0000000000000592.
https://p…
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psnet.ahrq.gov/node/60183/psn-pdf
April 01, 2020 - Elder abuse and neglect: an overlooked patient safety
issue. A focus group study of nursing home leaders'
perceptions of elder abuse and neglect.
April 1, 2020
Myhre J, Saga S, Malmedal W, et al. Elder abuse and neglect: an overlooked patient safety issue. A focus
group study of nursing home leaders’ perceptions o…
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psnet.ahrq.gov/node/37227/psn-pdf
December 15, 2011 - Intensive care unit safety incidents for medical versus
surgical patients: a prospective multicenter study.
December 15, 2011
Sinopoli DJ, Needham DM, Thompson DA, et al. Intensive care unit safety incidents for medical versus
surgical patients: a prospective multicenter study. J Crit Care. 2007;22(3):177-83.
http…
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psnet.ahrq.gov/node/857444/psn-pdf
December 06, 2023 - The relationship between nursing home staffing and
resident safety outcomes: a systematic review of reviews.
December 6, 2023
Blatter C, Osi?ska M, Simon M, et al. The relationship between nursing home staffing and resident safety
outcomes: a systematic review of reviews. Int J Nurs Stud. 2023;150:104641.
doi:10.1…
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psnet.ahrq.gov/node/60029/psn-pdf
March 11, 2020 - Prevalence, nature and predictors of omitted medication
doses in mental health hospitals: a multi-centre study.
March 11, 2020
Keers RN, Hann M, Alshehri GH, et al. Prevalence, nature and predictors of omitted medication doses in
mental health hospitals: A multi-centre study. PLoS One. 2020;15(2):e0228868.
doi:10.…
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psnet.ahrq.gov/node/73414/psn-pdf
June 23, 2021 - Promoting the psychological well-being of healthcare
providers facing the burden of adverse events: a
systematic review of second victim support resources.
June 23, 2021
Busch IM, Moretti F, Campagna I, et al. Promoting the psychological well-being of healthcare providers
facing the burden of adverse events: a sys…
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psnet.ahrq.gov/node/37586/psn-pdf
March 05, 2008 - National surveillance of emergency department visits for
outpatient adverse drug events in children and
adolescents.
March 5, 2008
Cohen AL, Budnitz DS, Weidenbach KN, et al. National surveillance of emergency department visits for
outpatient adverse drug events in children and adolescents. J Pediatr. 2008;152(3):…
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psnet.ahrq.gov/node/46200/psn-pdf
August 30, 2017 - Clinical practice guideline: safe medication use in the
ICU.
August 30, 2017
Kane-Gill SL, Dasta JF, Buckley MS, et al. Clinical Practice Guideline: Safe Medication Use in the ICU. Crit
Care Med. 2017;45(9):e877-e915. doi:10.1097/CCM.0000000000002533.
https://psnet.ahrq.gov/issue/clinical-practice-guideline-safe-m…
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psnet.ahrq.gov/node/46267/psn-pdf
December 21, 2017 - Pictograms, units and dosing tools, and parent
medication errors: a randomized study.
December 21, 2017
Yin S, Parker RM, Sanders LM, et al. Pictograms, Units and Dosing Tools, and Parent Medication Errors: A
Randomized Study. Pediatrics. 2017;140(1):e20163237. doi:10.1542/peds.2016-3237.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case April 2006
Is the “Surgical Personality” a Threat to Patient Safety?
Source and Credits
This presentation is based on the April 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary …
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psnet.ahrq.gov/node/33645/psn-pdf
February 01, 2007 - She
describes the pain as a burning sensation in the mid-
abdomen, pointing to the area just below
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psnet.ahrq.gov/node/49621/psn-pdf
March 01, 2011 - //psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
An extensive body of literature describes
-
psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - The Measurement of Patient Safety primer describes the framework for measuring patient safety based
-
psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - The Commentary This case describes a wrong-site surgery in which a patient had the wrong kidney removed
-
psnet.ahrq.gov/web-mm/missed-pneumonia
June 01, 2005 - Most literature regarding misdiagnosis of pneumonia describes overdiagnosis: attributing a constellation
-
psnet.ahrq.gov/node/33828/psn-pdf
March 01, 2017 - Sociological literature describes how easy it is to
exploit people in organizations by appealing to
-
psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
April 08, 2019 - This case describes a patient who wasn't served well by the people, processes, or products.
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
March 01, 2009 - Spotlight Case July 2008
Spotlight Case
All in the History
Source and Credits
This presentation is based on the February/March 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Christopher Fee, MD, University of California, San Francisco
…
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psnet.ahrq.gov/node/49727/psn-pdf
March 01, 2015 - Critical Opportunity Lost
March 1, 2015
Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/critical-opportunity-lost
The Case
A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She
reported eating a heavy dinner the pre…