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psnet.ahrq.gov/issue/post-event-debriefings-during-neonatal-care-why-are-we-not-doing-them-and-how-can-we-start
January 15, 2014 - 2014
Surgical management and outcomes of 165 colonoscopic perforations from a single institution
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psnet.ahrq.gov/issue/computerized-clinical-decision-support-medication-prescribing-and-utilization-pediatrics
July 16, 2015 - Preventability of voluntarily reported or trigger tool–identified medication errors in a pediatric institution
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psnet.ahrq.gov/issue/sbar-mm-feasible-reliable-and-valid-tool-assess-quality-surgical-morbidity-and-mortality
July 02, 2014 - Related Resources
Patient handoffs and multi-specialty trainee perspectives across an institution
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psnet.ahrq.gov/issue/progress-patient-safety-glass-fuller-it-seems
March 13, 2013 - National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution
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psnet.ahrq.gov/issue/association-between-surgical-trainee-daytime-sleepiness-and-intraoperative-technical-skill
June 27, 2018 - Taking a Syringe at Face Value in the Operating Room
June 1, 2019
Multiple-institution
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psnet.ahrq.gov/issue/perceptions-use-names-recognition-roles-and-teamwork-after-labeling-surgical-caps
March 18, 2009 - November 1, 2017
Bringing perioperative emergency manuals to your institution: a "How
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psnet.ahrq.gov/issue/intensive-care-unit-safety-culture-and-outcomes-us-multicenter-study
June 16, 2011 - Author(s)
Perceptions of safety culture vary across the intensive care units of a single institution
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psnet.ahrq.gov/issue/implementing-surgical-checklist-more-checking-box
July 16, 2014 - Operating room clinicians' attitudes and perceptions of a pediatric surgical safety checklist at 1 institution
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psnet.ahrq.gov/issue/implementing-peer-evaluation-handoffs-associations-experience-and-workload
February 19, 2013 - January 18, 2013
An institution-wide handoff task force to standardise and improve physician
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psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
December 01, 2017 - community-acquired pneumonia), and suggest appropriate orders or order sets as a result.( 3 ) At our institution—like … optimal design of electrolyte repletion orders and order sets is not entirely clear and may vary from institution … to institution.
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psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
April 24, 2018 - At our institution, wet reads are documented in the electronic medical record, then tracked and adjudicated … Subcritical findings were found in approximately 3.3% of cases at our institution in 2015, comparable … for discrepancy rates in preliminary interpretations provided by radiology trainees at an academic institution
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psnet.ahrq.gov/web-mm/abnormal-volunteer-results
July 18, 2016 - merit and ethical issues raised by the research, with at least one member at arm's length from the institution … Although an institution may approve or disapprove research approved by its IRB, the institution may not
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psnet.ahrq.gov/node/49562/psn-pdf
May 01, 2008 - practical perspective, the exact manner in which the time out is conducted varies considerably from
institution … to institution—in timing, content, and documentation. … Each institution should decide how the Universal Protocol and time out are documented, but care
must
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psnet.ahrq.gov/node/33764/psn-pdf
April 01, 2014 - This needs to become a standard and an
expectation that it will be this way in every institution. … : When this job opened up, you were in a very prominent role in patient safety at a world-renowned
institution … I've had an impact on patient safety at a local institution, at a hospital
level, and at a health system … innovative technologies, which I don't even know what they will be in 10 years, to ensure that if
an institution
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psnet.ahrq.gov/issue/multidisciplinary-team-approach-retained-foreign-objects
June 10, 2010 - National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution
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psnet.ahrq.gov/issue/measuring-hospital-adverse-events-assessing-inter-rater-reliability-and-trigger-performance
May 07, 2014 - National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution
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psnet.ahrq.gov/issue/risk-sensitive-events-during-laparoscopic-cholecystectomy-influence-integrated-operating-room
March 18, 2013 - April 12, 2017
Drug administration errors in an institution for individuals with intellectual
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psnet.ahrq.gov/issue/physician-staffing-models-and-patient-safety-icu
May 27, 2011 - activation is associated with increased hospital mortality, morbidity, and length of stay in a tertiary care institution
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psnet.ahrq.gov/issue/preliminary-taxonomy-medical-errors-family-practice
April 08, 2011 - April 24, 2018
Multiple-institution comparison of resident and faculty perceptions of
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psnet.ahrq.gov/issue/implementing-sbar-across-large-multihospital-health-system
November 23, 2014 - Related Resources
Patient handoffs and multi-specialty trainee perspectives across an institution