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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…
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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…
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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…
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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…
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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/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://…
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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…
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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):…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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://…
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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…
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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…
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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…