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psnet.ahrq.gov/node/47987/psn-pdf
May 08, 2019 - Association between night-time surgery and occurrence
of intraoperative adverse events and postoperative
pulmonary complications.
May 8, 2019
Cortegiani A, Gregoretti C, Neto AS, et al; LAS VEGAS Investigators, PROVE Network, Clinical Trial
Network of the European Society of Anaesthesiology. Br J Anaesth. 2019;122…
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psnet.ahrq.gov/node/46362/psn-pdf
January 01, 2021 - Making patient safety event data actionable:
understanding patient safety analyst needs.
October 4, 2017
Puthumana JS, Fong A, Blumenthal J, et al. Making Patient Safety Event Data Actionable: Understanding
Patient Safety Analyst Needs. J Patient Saf. 2021;17(6):e509-e514. doi:10.1097/pts.0000000000000400.
https:/…
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psnet.ahrq.gov/node/855091/psn-pdf
November 08, 2023 - Handoff tool improves transitions from the operating
room to the neonatal intensive care unit.
November 8, 2023
Gallois JB, Zagory JA, Barkemeyer B, et al. Handoff tool improves transitions from the operating room to
the neonatal intensive care unit. Pediatr Qual Saf. 2023;8(5):e695. doi:10.1097/pq9.000000000000069…
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psnet.ahrq.gov/node/46703/psn-pdf
August 01, 2018 - Measurement of harms in community care: a qualitative
study of use of the NHS Safety Thermometer.
August 1, 2018
Brewster L, Tarrant C, Willars J, et al. Measurement of harms in community care: a qualitative study of use
of the NHS Safety Thermometer. BMJ Qual Saf. 2018;27(8):625-632. doi:10.1136/bmjqs-2017-006970.…
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psnet.ahrq.gov/node/73439/psn-pdf
June 30, 2021 - Nurses as 'second victims' to their patients' suicidal
attempts: a mixed-method study.
June 30, 2021
Amit Aharon A, Fariba M, Shoshana F, et al. Nurses as ‘second victims’ to their patients’ suicidal attempts:
a mixed?method study. J Clin Nurs. 2021;30(21-22):3290-3300. doi:10.1111/jocn.15839.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/850914/psn-pdf
June 21, 2023 - A call for safety: anticipating and mitigating risk across
an obstetrics and gynecology service line.
June 21, 2023
Combs A, Klein VR. A call for safety: anticipating and mitigating risk across an obstetrics and gynecology
service line. J Healthc Risk Manag. 2023;43(1):38-42. doi:10.1002/jhrm.21538.
https://psnet.…
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psnet.ahrq.gov/node/44942/psn-pdf
September 29, 2017 - Challenges in patient safety improvement research in the
era of electronic health records.
September 29, 2017
Russo E, Sittig DF, Murphy DR, et al. Challenges in patient safety improvement research in the era of
electronic health records. Healthc (Amst). 2016;4(4):285-290. doi:10.1016/j.hjdsi.2016.06.005.
https://…
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psnet.ahrq.gov/node/46858/psn-pdf
May 11, 2019 - Evidence review conducted for the Agency for Healthcare
Research and Quality Safety Program for Improving
Surgical Care and Recovery: focus on anesthesiology for
colorectal surgery.
May 11, 2019
Ban KA, Gibbons MM, Ko CY, et al. Evidence Review Conducted for the Agency for Healthcare Research
and Quality Safety …
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psnet.ahrq.gov/node/853059/psn-pdf
August 30, 2023 - Anesthesia Risk Alert program: a proactive safety
initiative.
August 30, 2023
Lee B, Marhalik-Helms J, Penzi L. Anesthesia Risk Alert program: a proactive safety initiative. Jt Comm J
Qual Patient Saf. 2023;49(9):441-449. doi:10.1016/j.jcjq.2023.06.005.
https://psnet.ahrq.gov/issue/anesthesia-risk-alert-program-pr…
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psnet.ahrq.gov/node/36025/psn-pdf
March 28, 2011 - Understanding diagnostic errors in medicine: a lesson
from aviation.
March 28, 2011
Singh H, Petersen LA, Thomas EJ. Understanding diagnostic errors in medicine: a lesson from aviation.
Qual Saf Health Care. 2006;15(3):159-64.
https://psnet.ahrq.gov/issue/understanding-diagnostic-errors-medicine-lesson-aviation
T…
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psnet.ahrq.gov/node/44470/psn-pdf
October 13, 2015 - Workplace training for senior trainees: a systematic
review and narrative synthesis of current approaches to
promote patient safety.
October 13, 2015
Walton M, Harrison R, Burgess A, et al. Workplace training for senior trainees: a systematic review and
narrative synthesis of current approaches to promote patient …
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psnet.ahrq.gov/node/45108/psn-pdf
October 11, 2017 - IT-CARES: an interactive tool for case-crossover analyses
of electronic medical records for patient safety.
October 11, 2017
Caron A, Chazard E, Muller J, et al. IT-CARES: an interactive tool for case-crossover analyses of electronic
medical records for patient safety. J Am Med Inform Assoc. 2017;24(2):323-330.
do…
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psnet.ahrq.gov/node/45643/psn-pdf
November 30, 2016 - Sources and magnitude of error in preparing morphine
infusions for nurse–patient controlled analgesia in a UK
paediatric hospital.
November 30, 2016
Rashed AN, Tomlin S, Aguado V, et al. Sources and magnitude of error in preparing morphine infusions for
nurse-patient controlled analgesia in a UK paediatric hospita…
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psnet.ahrq.gov/node/47103/psn-pdf
August 22, 2018 - Understanding procedural violations using Safety-I and
Safety-II: the case of community pharmacies.
August 22, 2018
Jones CEL, Phipps D, Ashcroft DM. Understanding procedural violations using Safety-I and Safety-II: The
case of community pharmacies. Saf Sci. 2018;105:114-120. doi:10.1016/j.ssci.2018.02.002.
https:…
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psnet.ahrq.gov/node/72482/psn-pdf
November 18, 2020 - Real-time debriefing after critical events: exploring the
gap between principle and reality.
November 18, 2020
Arriaga AF, Szyld D, Pian-Smith MCM. Real-time debriefing after critical events: exploring the gap between
principle and reality. Anesthesiol Clin. 2020;38(4):801-820. doi:10.1016/j.anclin.2020.08.003.
ht…
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psnet.ahrq.gov/node/45357/psn-pdf
October 09, 2016 - Leading article: how can I optimise my role as a leader
within the surgical team?
October 9, 2016
Green B, Mitchell DA, Stevenson P, et al. Leading article: how can I optimise my role as a leader within the
surgical team? Br J Oral Maxillofac Surg. 2016;54(8):847-850. doi:10.1016/j.bjoms.2016.05.035.
https://psnet…
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psnet.ahrq.gov/node/48138/psn-pdf
July 17, 2019 - Beyond the clinical team: evaluating the human factors-
oriented training of non-clinical professionals working in
healthcare contexts.
July 17, 2019
Lavelle M, Reedy GB, Attoe C, et al. Beyond the clinical team: evaluating the human factors-oriented
training of non-clinical professionals working in healthcare con…
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psnet.ahrq.gov/node/38799/psn-pdf
September 29, 2009 - Work-arounds and artifacts during transition to a
computer physician order entry: what they are and what
they mean.
September 29, 2009
Schoville RR. Work-arounds and artifacts during transition to a computer physician order entry: what they
are and what they mean. J Nurs Care Qual. 2009;24(4):316-324. doi:10.1097/…
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psnet.ahrq.gov/node/46116/psn-pdf
May 24, 2017 - Elimination of emergency department medication errors
due to estimated weights.
May 24, 2017
Greenwalt M, Griffen D, Wilkerson J. Elimination of Emergency Department Medication Errors Due To
Estimated Weights. BMJ Qual Improv Rep. 2017;6(1). doi:10.1136/bmjquality.u214416.w5476.
https://psnet.ahrq.gov/issue/elimin…
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psnet.ahrq.gov/node/74056/psn-pdf
January 01, 2022 - Critical care simulation education program during the
COVID-19 pandemic.
November 10, 2021
Leibner ES, Baron EL, Shah RS, et al. Critical care simulation education program during the COVID-19
pandemic. J Patient Saf. 2022;18(4):e810-e815. doi:10.1097/pts.0000000000000928.
https://psnet.ahrq.gov/issue/critical-care…