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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35549/psn-pdf
    March 03, 2011 - A human factors analysis of technical and team skills among surgical trainees during procedural simulations in a simulated operating theatre. March 3, 2011 Moorthy K, Munz Y, Adams S, et al. A human factors analysis of technical and team skills among surgical trainees during procedural simulations in a simulated o…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60674/psn-pdf
    July 08, 2020 - Sway: Unravelling Unconscious Bias July 8, 2020 Agarwal P. London, UK: Bloomsbury Sigma; 2020. ISBN 9781472971357.  https://psnet.ahrq.gov/issue/sway-unravelling-unconscious-bias Implicit biases influence behavior and decision making. This publication discusses how a range of implicit biases affect legal…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40328/psn-pdf
    September 27, 2016 - Critical phase distractions in anaesthesia and the sterile cockpit concept. September 27, 2016 Broom MA, Capek AL, Carachi P, et al. Critical phase distractions in anaesthesia and the sterile cockpit concept. Anaesthesia. 2011;66(3):175-179. doi:10.1111/j.1365-2044.2011.06623.x. https://psnet.ahrq.gov/issue/critic…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37375/psn-pdf
    December 05, 2007 - Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. December 5, 2007 Vidyarthi AR, Arora V, Schnipper JL, et al. Managing discontinuity in academic medical centers: Strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1(4). doi:10.1002/jhm.10…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37312/psn-pdf
    January 05, 2012 - Delineation of risk through the exploration of a culture of safety in community home health. January 5, 2012 Stevenson L, McRae C, Mughal WA. Delineation of Risk Through the Exploration of a Culture of Safety in Community Home Health. Home Health Care Manag Pract. 2007;19(6). doi:10.1177/1084822307304256. https://…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34790/psn-pdf
    December 23, 2008 - Cognitive errors in diagnosis: instantiation, classification, and consequences. December 23, 2008 Kassirer JP, Kopelman RI. Cognitive errors in diagnosis: instantiation, classification, and consequences. Am J Med. 1989;86(4):433-41. https://psnet.ahrq.gov/issue/cognitive-errors-diagnosis-instantiation-classificati…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35073/psn-pdf
    January 01, 2016 - The role of teamwork in the professional education of physicians: current status and assessment recommendations. March 29, 2007 Baker DP, Salas E, King HB, et al. The Role of Teamwork in the Professional Education of Physicians: Current Status and Assessment Recommendations. Jt Comm J Qual Patient Saf. 2016;31(4):…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47668/psn-pdf
    January 30, 2019 - Organizing for Reliability: A Guide for Research and Practice. January 30, 2019 Ramanujam R, Roberts KH, eds. Stanford, CA: Stanford University Press; 2018. ISBN: 9780804793612. https://psnet.ahrq.gov/issue/organizing-reliability-guide-research-and-practice High reliability principles guide safety efforts in compl…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836832/psn-pdf
    March 30, 2022 - Improving Education—A Key to Better Diagnostic Outcomes. March 30, 2022 Olson APJ, Danielson J, Stanley J, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2022. AHRQ Publication No. 22-0026-1-EF https://psnet.ahrq.gov/issue/improving-education-key-better-diagnostic-outcomes Diagnostic skil…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60164/psn-pdf
    March 25, 2020 - Patient Safety, Spring 2019 Final CDP Report. March 25, 2020 Patient Safety Standing Committee. February 6, 2020. Washington DC; National Quality Forum. February 2020. https://psnet.ahrq.gov/issue/patient-safety-spring-2019-final-cdp-report The development of effective measures to document and track patient safety…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46316/psn-pdf
    August 02, 2017 - Defending a "never event." August 2, 2017 Shepperd JR. Defending a "Never Event". J Healthc Risk Manag. 2017;37(1):17-22. doi:10.1002/jhrm.21277. https://psnet.ahrq.gov/issue/defending-never-event Surgical fires are considered a never event. This commentary provides an overview of surgical fires, explains element…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72514/psn-pdf
    November 25, 2020 - AI is wrestling with a replication crisis. November 25, 2020 Heaven WD. MIT Technology Review. November 12, 2020. https://psnet.ahrq.gov/issue/ai-wrestling-replication-crisis Lack of transparency of research and development processes are thought to undermine the value of artificial intelligence (AI) and trust in i…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43460/psn-pdf
    April 25, 2016 - Safety organizing, emotional exhaustion, and turnover in hospital nursing units. April 25, 2016 Vogus TJ, Cooil B, Sitterding M, et al. Safety organizing, emotional exhaustion, and turnover in hospital nursing units. Med Care. 2014;52(10):870-6. doi:10.1097/MLR.0000000000000169. https://psnet.ahrq.gov/issue/safety…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45835/psn-pdf
    February 01, 2017 - Deploying and measuring a risk and patient safety program. February 1, 2017 Orel H, McGroarty M, Marchegiani H. Deploying and measuring a risk and patient safety program. J Healthc Risk Manag. 2017;36(3):26-33. doi:10.1002/jhrm.21266. https://psnet.ahrq.gov/issue/deploying-and-measuring-risk-and-patient-safety-pro…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36411/psn-pdf
    December 22, 2010 - Minimising human error in malaria rapid diagnosis: clarity of written instructions and health worker performance. December 22, 2010 Rennie W, Phetsouvanh R, Lupisan S, et al. Minimising human error in malaria rapid diagnosis: clarity of written instructions and health worker performance. Trans R Soc Trop Med Hyg. 2…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38340/psn-pdf
    April 19, 2011 - What is the scale of prescribing errors committed by junior doctors? A systematic review. April 19, 2011 Ross S, Bond C, Rothnie H, et al. What is the scale of prescribing errors committed by junior doctors? A systematic review. Br J Clin Pharmacol. 2009;67(6):629-40. doi:10.1111/j.1365-2125.2008.03330.x. https://…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42442/psn-pdf
    July 24, 2013 - Using Plan Do Study Act to transform a simulation center. July 24, 2013 Murphy JI. Using Plan Do Study Act to Transform a Simulation Center. Clin Simul Nurs. 2012;9(7). doi:10.1016/j.ecns.2012.03.002. https://psnet.ahrq.gov/issue/using-plan-do-study-act-transform-simulation-center This commentary describes the res…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43183/psn-pdf
    May 14, 2014 - Physician: 'I almost killed a patient' because of an advance directive. May 14, 2014 Betbeze P. HealthLeaders Media. May 2, 2014. https://psnet.ahrq.gov/issue/physician-i-almost-killed-patient-because-advance-directive Reporting on how misinterpretation of advance directives and living wills can detract from patie…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45229/psn-pdf
    July 13, 2016 - The WakeWings journey: creating a patient safety program. July 13, 2016 Mills E. The WakeWings Journey: Creating a Patient Safety Program. AORN J. 2016;103(6):636-9. doi:10.1016/j.aorn.2016.04.004. https://psnet.ahrq.gov/issue/wakewings-journey-creating-patient-safety-program Successful and sustainable implementa…

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