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psnet.ahrq.gov/node/37119/psn-pdf
March 24, 2011 - Patient safety: helping medical students understand error
in healthcare.
March 24, 2011
Patey R, Flin R, Cuthbertson BH, et al. Patient safety: helping medical students understand error in
healthcare. Qual Saf Health Care. 2007;16(4):256-9.
https://psnet.ahrq.gov/issue/patient-safety-helping-medical-students-under…
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psnet.ahrq.gov/node/36148/psn-pdf
March 03, 2011 - Surgical crisis management skills training and
assessment: a stimulation-based approach to enhancing
operating room performance.
March 3, 2011
Moorthy K, Munz Y, Forrest D, et al. Surgical Crisis Management Skills Training and Assessment. Ann
Surg. 2006;244(1). doi:10.1097/01.sla.0000217618.30744.61.
https://psne…
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psnet.ahrq.gov/node/73380/psn-pdf
June 09, 2021 - Wrong Site Surgery–Wrong Tooth Extraction.
June 9, 2021
Farnborough, UK: Healthcare Safety Investigation Branch; April 2021.
https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-tooth-extraction
Wrong-site surgery in dentistry is a frequent and persistent never event. This report examines a case of
pediatric wron…
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psnet.ahrq.gov/node/36387/psn-pdf
July 14, 2010 - Effectiveness of a community collaborative for
eliminating the use of high-risk abbreviations written by
physicians.
July 14, 2010
Leonhardt KK, Botticelli J. Effectiveness of a Community Collaborative for Eliminating the Use of High-risk
Abbreviations Written by Physicians. J Patient Saf. 2008;2(3). doi:10.1097/0…
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psnet.ahrq.gov/node/43354/psn-pdf
July 16, 2014 - Weaving a healthcare tapestry of safety and
communication.
July 16, 2014
Hay J, Collin S, Koruth S. Weaving a healthcare tapestry of safety and communication. Nurs Manage.
2014;45(7):40-6. doi:10.1097/01.NUMA.0000451035.84587.7d.
https://psnet.ahrq.gov/issue/weaving-healthcare-tapestry-safety-and-communication
Th…
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psnet.ahrq.gov/node/44277/psn-pdf
July 01, 2015 - When should surgeons stop operating?
July 1, 2015
Whitehead N. National Public Radio. June 18, 2015.
https://psnet.ahrq.gov/issue/when-should-surgeons-stop-operating
The competency of surgeons as they age has been debated as a risk to patient safety. This news article
describes concerns about the aging population …
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psnet.ahrq.gov/node/37163/psn-pdf
May 04, 2015 - A medication safety education program to reduce the risk
of harm caused by medication errors.
May 4, 2015
Dennison RD. A medication safety education program to reduce the risk of harm caused by medication
errors. J Contin Educ Nurs. 2007;38(4):176-84.
https://psnet.ahrq.gov/issue/medication-safety-education-progra…
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psnet.ahrq.gov/node/38008/psn-pdf
August 27, 2008 - The Team Climate Inventory: application in hospital teams
and methodological considerations.
August 27, 2008
Ouwens M, Hulscher M, Akkermans R, et al. The Team Climate Inventory: application in hospital teams
and methodological considerations. Qual Saf Health Care. 2008;17(4):275-80.
doi:10.1136/qshc.2006.021543.
…
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psnet.ahrq.gov/node/40999/psn-pdf
January 01, 2012 - Improving patient safety via automated laboratory-based
adverse event grading.
December 15, 2011
Niland JC, Stiller T, Neat J, et al. Improving patient safety via automated laboratory-based adverse event
grading. J Am Med Inform Assoc. 2012;19(1):111-5. doi:10.1136/amiajnl-2011-000513.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/35976/psn-pdf
August 10, 2010 - Guidelines for prevention, diagnosis and treatment of
ventilator-associated pneumonia (VAP) in the trauma
patient.
August 10, 2010
Minei JP, Nathens AB, West M, et al. Guidelines for prevention, diagnosis and treatment of ventilator-
associated pneumonia (VAP) in the trauma patient. J Trauma. 2006;60(5):1106-1113.…
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psnet.ahrq.gov/node/47371/psn-pdf
September 26, 2018 - When I say…diagnostic error.
September 26, 2018
Hautz WE. When I say… diagnostic error. Med Educ. 2018. doi:10.1111/medu.13602.
https://psnet.ahrq.gov/issue/when-i-saydiagnostic-error
Inconsistent terminology use in research, education, and measurement strategy development hinders
progress and understanding in eme…
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psnet.ahrq.gov/node/37898/psn-pdf
July 09, 2008 - Patient safety in obstetrics: what aviators, firefighters and
others can teach us.
July 9, 2008
Guise J-M, Lowe NK, Connell L. Patient Safety in Obstetrics: What Aviators, Firefighters and Others Can
Teach Us. Nurs Womens Health. 2008;12(3):208-215. doi:10.1111/j.1751-486x.2008.00325.x.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/35443/psn-pdf
September 18, 2009 - The nuclear power industry as an alternative analogy for
safety in anaesthesia and a novel approach for the
conceptualisation of safety goals.
September 18, 2009
Webster CS. The nuclear power industry as an alternative analogy for safety in anaesthesia and a novel
approach for the conceptualisation of safety goals…
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psnet.ahrq.gov/node/44029/psn-pdf
April 25, 2016 - Accelerating the adoption of a safety culture.
April 25, 2016
Birk S. Accelerating the Adoption of a Safety Culture. Healthcare Executive. 2015;30(2):18-20, 22-24, 26.
https://psnet.ahrq.gov/issue/accelerating-adoption-safety-culture
Hospital senior managers have been challenged to establish a safety culture in the…
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - new teamwork training program, or narrowly addressing interruptions of oral handoffs, we thought that developing
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psnet.ahrq.gov/web-mm/snfs-opening-black-box
August 27, 2012 - teamstepps.ahrq.gov/ QAPI for Nursing Homes—CMS has produced tools and resources to assist nursing homes with developing
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psnet.ahrq.gov/node/73103/psn-pdf
March 31, 2021 - As a
result, a developing skin infection could have been missed by the nursing staff.
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - generally avoidable with the implementation of quality improvement measures. 3 Current policies emphasize developing
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psnet.ahrq.gov/node/49651/psn-pdf
May 01, 2012 - As a
result, programs are currently developing new handoff curricula.(4) Because programs must also
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psnet.ahrq.gov/issue/residents-responsibility-and-error-how-residents-learn-navigate-intersection
August 21, 2019 - Study
Residents, responsibility, and error: how residents learn to navigate the intersection.
Citation Text:
Shepherd L, Chilton S, Cristancho SM. Residents, responsibility, and error: how residents learn to navigate the intersection. Acad Med. 2023;98(8):934-940. doi:10.1097/acm.0000000…