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psnet.ahrq.gov/node/42692/psn-pdf
April 21, 2015 - Surgical skill and complication rates after bariatric
surgery.
April 21, 2015
Birkmeyer JD, Finks JF, O'Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl
J Med. 2013;369(15):1434-1442. doi:10.1056/NEJMsa1300625.
https://psnet.ahrq.gov/issue/surgical-skill-and-complication-rates…
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psnet.ahrq.gov/node/35611/psn-pdf
June 23, 2010 - Error or "act of God"? A study of patients' and operating
room team members' perceptions of error definition,
reporting, and disclosure.
June 23, 2010
Espin S, Levinson W, Regehr G, et al. Error or "act of God"? A study of patients' and operating room team
members' perceptions of error definition, reporting, and d…
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psnet.ahrq.gov/node/34068/psn-pdf
July 10, 2008 - Pharmacists on rounding teams reduce preventable
adverse drug events in hospital general medicine units.
July 10, 2008
Kucukarslan SN, Peters M, Mlynarek M, et al. Pharmacists on rounding teams reduce preventable adverse
drug events in hospital general medicine units. Arch Intern Med. 2003;163(17):2014-8.
https://…
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psnet.ahrq.gov/node/39748/psn-pdf
August 11, 2010 - Information transfer and communication in surgery: a
systematic review.
August 11, 2010
Nagpal K, Vats A, Lamb B, et al. Information transfer and communication in surgery: a systematic review.
Ann Surg. 2010;252(2):225-39. doi:10.1097/SLA.0b013e3181e495c2.
https://psnet.ahrq.gov/issue/information-transfer-and-comm…
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psnet.ahrq.gov/node/34892/psn-pdf
February 03, 2011 - Effects of computerized clinical decision support systems
on practitioner performance and patient outcomes: a
systematic review.
February 3, 2011
Garg AX, Adhikari NKJ, McDonald H, et al. Effects of Computerized Clinical Decision Support Systems on
Practitioner Performance and Patient Outcomes. JAMA. 2005;293(10):…
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psnet.ahrq.gov/node/42473/psn-pdf
August 13, 2013 - Surgical technology and operating-room safety failures: a
systematic review of quantitative studies.
August 13, 2013
Weerakkody RA, Cheshire NJ, Riga C, et al. Surgical technology and operating-room safety failures: a
systematic review of quantitative studies. BMJ Qual Saf. 2013;22(9):710-8. doi:10.1136/bmjqs-2012-…
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psnet.ahrq.gov/node/848110/psn-pdf
April 26, 2023 - has been recommended that fall prevention interventions comprise a multicomponent
approach5,8-10 and incorporate … residents.23 Designing interventions based on social and cognitive theories may help staff and residents
incorporate
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - EHR systems should incorporate easily seen indicators and notifications when hemolysis is detected. … awareness of long QT syndrome: Similar to alerts for patient allergies or device implants, EHRs should incorporate
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psnet.ahrq.gov/node/42230/psn-pdf
October 06, 2016 - Using Lean to improve medication administration safety:
in search of the "perfect dose."
October 6, 2016
Ching JM, Long C, Williams BL, et al. Using lean to improve medication administration safety: in search of
the "perfect dose". Jt Comm J Qual Patient Saf. 2013;39(5):195-204.
https://psnet.ahrq.gov/issue/using-…
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psnet.ahrq.gov/node/37112/psn-pdf
May 26, 2011 - The impact of a closed-loop electronic prescribing and
administration system on prescribing errors,
administration errors and staff time: a before-and-after
study.
May 26, 2011
Franklin BD, O'Grady K, Donyai P, et al. The impact of a closed-loop electronic prescribing and
administration system on prescribing erro…
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psnet.ahrq.gov/node/37345/psn-pdf
May 26, 2011 - Impact of computerized prescriber order entry on the
incidence of adverse drug events in pediatric inpatients.
May 26, 2011
Holdsworth MT, Fichtl RE, Raisch DW, et al. Impact of computerized prescriber order entry on the
incidence of adverse drug events in pediatric inpatients. Pediatrics. 2007;120(5):1058-66.
htt…
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psnet.ahrq.gov/node/42154/psn-pdf
January 07, 2015 - Paper- and computer-based workarounds to electronic
health record use at three benchmark institutions.
January 7, 2015
Flanagan ME, Saleem JJ, Millitello LG, et al. Paper- and computer-based workarounds to electronic health
record use at three benchmark institutions. J Am Med Inform Assoc. 2013;20(e1):e59-66.
doi:…
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psnet.ahrq.gov/node/47491/psn-pdf
November 07, 2018 - Integrating patient safety education into early medical
education utilizing cadaver, sponges, and an inter-
professional team.
November 7, 2018
Kutaimy R, Zhang L, Blok D, et al. Integrating patient safety education into early medical education utilizing
cadaver, sponges, and an inter-professional team. BMC Med Ed…
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psnet.ahrq.gov/node/37874/psn-pdf
April 18, 2011 - Interprofessional handover and patient safety in
anaesthesia: observational study of handovers in the
recovery room.
April 18, 2011
Smith AF, Pope C, Goodwin D, et al. Interprofessional handover and patient safety in anaesthesia:
observational study of handovers in the recovery room. Br J Anaesth. 2008;101(3):332-…
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psnet.ahrq.gov/node/41317/psn-pdf
January 31, 2013 - Variation in 17 obstetric care pathways: potential danger
for health professionals and patient safety?
January 31, 2013
Sarrechia M, Van Gerven E, Hermans L, et al. Variation in 17 obstetric care pathways: potential danger for
health professionals and patient safety? J Adv Nurs. 2013;69(2):278-85. doi:10.1111/j.136…
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psnet.ahrq.gov/node/46027/psn-pdf
July 02, 2019 - Dissecting Leapfrog: how well do Leapfrog Safe Practices
Scores correlate with Hospital Compare ratings and
penalties, and how much do they matter?
July 2, 2019
Smith SN, Reichert HA, Ameling JM, et al. Dissecting Leapfrog: How Well Do Leapfrog Safe Practices
Scores Correlate With Hospital Compare Ratings and Pena…
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psnet.ahrq.gov/issue/escape-room
April 30, 2024 - Tools/Toolkit
Escape Room.
Citation Text:
Escape Room. Harrisburg, PA: Pennsylvania Safety Authority; 2020.
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psnet.ahrq.gov/node/840255/psn-pdf
November 16, 2022 - Using Human Factors Engineering and the SEIPS Model
to Advance Patient Safety in Care Transitions
November 16, 2022
Carayon P, Werner N, Makkenchery A, et al. Using Human Factors Engineering and the SEIPS Model to
Advance Patient Safety in Care Transitions . PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspecti…
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psnet.ahrq.gov/node/45380/psn-pdf
November 11, 2016 - Innovative patient safety curriculum using iPad game
(PASSED) improved patient safety concepts in
undergraduate medical students.
November 11, 2016
Kow AWC, Ang BLS, Chong CS, et al. Innovative Patient Safety Curriculum Using iPAD Game (PASSED)
Improved Patient Safety Concepts in Undergraduate Medical Students. Wo…
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psnet.ahrq.gov/node/39302/psn-pdf
February 17, 2010 - Preoperative briefing in the operating room: shared
cognition, teamwork, and patient safety.
February 17, 2010
Einav Y, Gopher D, Kara I, et al. Preoperative briefing in the operating room: shared cognition, teamwork,
and patient safety. Chest. 2010;137(2):443-9. doi:10.1378/chest.08-1732.
https://psnet.ahrq.gov/i…