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psnet.ahrq.gov/node/40915/psn-pdf
January 04, 2012 - Simulation in obstetric anesthesia.
January 4, 2012
Pratt SD. Focused review: simulation in obstetric anesthesia. Anesth Analg. 2012;114(1):186-90.
doi:10.1213/ANE.0b013e3182377bbc.
https://psnet.ahrq.gov/issue/simulation-obstetric-anesthesia
This review examines how simulation training can improve performance, id…
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psnet.ahrq.gov/node/38389/psn-pdf
February 04, 2009 - ADEs and automation.
February 4, 2009
Kloppenborg E, Wheeler A, Luria J. ADEs and automation. Nurs Manage. 2009;40(1):43-7.
doi:10.1097/01.NUMA.0000343983.46376.31.
https://psnet.ahrq.gov/issue/ades-and-automation
This article illustrates how one hospital used automated triggers to collect adverse drug event (ADE)…
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psnet.ahrq.gov/node/36918/psn-pdf
September 01, 2011 - Developing a culture of safety in ambulatory care
settings.
September 1, 2011
Shostek K. Developing a culture of safety in ambulatory care settings. J Ambul Care Manage.
2007;30(2):105-13.
https://psnet.ahrq.gov/issue/developing-culture-safety-ambulatory-care-settings
The author discusses the issues involved in e…
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psnet.ahrq.gov/node/36218/psn-pdf
October 18, 2010 - Disclosing adverse events: you said it, now write it.
October 18, 2010
Monson MS. Disclosing adverse events: you said it, now write it. Nurs Manage. 2006;37(8):16-7, 55.
https://psnet.ahrq.gov/issue/disclosing-adverse-events-you-said-it-now-write-it
This article discusses how to properly document an adverse event.
…
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psnet.ahrq.gov/node/37716/psn-pdf
October 02, 2017 - The impact of transparency on patient safety and liability.
October 2, 2017
Griffen D. The impact of transparency on patient safety and liability. Bull Am Coll Surg. 2008;93(3):19-23.
https://psnet.ahrq.gov/issue/impact-transparency-patient-safety-and-liability
This commentary describes how transparent disclosure o…
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psnet.ahrq.gov/node/40833/psn-pdf
October 05, 2011 - Personal best.
October 5, 2011
Gawande A. New Yorker. October 3, 2011.
https://psnet.ahrq.gov/issue/personal-best
This magazine article explores the role of coaches in helping high-performing professionals, such as
musicians and athletes, improve their performance. By submitting to observation in the operating roo…
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psnet.ahrq.gov/node/39809/psn-pdf
September 01, 2010 - Medical Errors and Safety Systems.
September 1, 2010
Pearlman MD, ed. Clin Obstet Gynecol. 2010;53(3):471-585.
https://psnet.ahrq.gov/issue/medical-errors-and-safety-systems
This special issue provides articles that discuss leadership roles, human factors, risk management, and
data collection concepts that …
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psnet.ahrq.gov/node/39849/psn-pdf
September 15, 2010 - The need for risk profiling in patient safety.
September 15, 2010
Donaldson LJ, Noble DJ. The need for risk profiling in patient safety. J Patient Saf. 2010;6(3):125-7.
doi:10.1097/PTS.0b013e3181ed73a3.
https://psnet.ahrq.gov/issue/need-risk-profiling-patient-safety
This commentary describes the need for health ca…
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psnet.ahrq.gov/node/41773/psn-pdf
September 30, 2015 - Serious Safety Events: Getting to Zero. Second Edition.
September 30, 2015
Hoppes M, Mitchell JL. Chicago, IL: American Society for Healthcare Risk Management; October 2014.
https://psnet.ahrq.gov/issue/serious-safety-events-getting-zero-second-edition
This white paper defines serious safety events and describes me…
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psnet.ahrq.gov/node/37720/psn-pdf
June 13, 2011 - Deploying med reconciliation.
June 13, 2011
Williams T, Acton C, Hicks RW. Deploying med reconciliation. Nurs Manage. 2008;39(4):54-7.
doi:10.1097/01.NUMA.0000316062.73435.f4.
https://psnet.ahrq.gov/issue/deploying-med-reconciliation
This commentary describes how one medical center developed a medication reconcili…
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psnet.ahrq.gov/node/35953/psn-pdf
May 24, 2006 - Too exhausted to act safely?
May 24, 2006
Spath P. Hosp Peer Rev. 2006;31(4):56-59.
https://psnet.ahrq.gov/issue/too-exhausted-act-safely
The author discusses how to identify and evaluate worker fatigue. Part II of this article outlines specific
techniques for reducing health care worker fatigue.
https://psnet.ah…
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psnet.ahrq.gov/node/36232/psn-pdf
October 19, 2010 - Building a safety net.
October 19, 2010
Rogoski RR. Building a safety net. By leveraging huge amounts of data and applying it to a wide array of
projects and purposes, hospitals stay focused on patient safety and make headway. Health management
technology. 2006;27(8):12-4, 16.
https://psnet.ahrq.gov/issue/building…
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psnet.ahrq.gov/node/41292/psn-pdf
October 20, 2015 - How to master the new art of training: teamwork on the
fly.
October 20, 2015
Edmondson AC. Harv Bus Rev. April 2012;90:72-80.
https://psnet.ahrq.gov/issue/how-master-new-art-training-teamwork-fly
This piece discusses the challenges of forming temporary teams in emergency departments and describes
strategies to im…
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psnet.ahrq.gov/node/60790/psn-pdf
February 23, 2022 - errors (e.g., leaving cement in the sulcus), can all jeopardize patient safety and quality of
care.66 Managing
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psnet.ahrq.gov/node/41864/psn-pdf
November 21, 2012 - Decision-making and safety in anesthesiology.
November 21, 2012
Stiegler MP, Ruskin KJ. Decision-making and safety in anesthesiology. Curr Opin Anaesthesiol.
2012;25(6):724-729. doi:10.1097/ACO.0b013e328359307a.
https://psnet.ahrq.gov/issue/decision-making-and-safety-anesthesiology
This review recommends decision-…
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psnet.ahrq.gov/node/38577/psn-pdf
April 22, 2009 - Leading your organization to high reliability.
April 22, 2009
Kemper C, Boyle DK. Leading your organization to high reliability. Nurs Manag. 2009;40(4):14-18.
doi:10.1097/01.NUMA.0000349684.24165.68.
https://psnet.ahrq.gov/issue/leading-your-organization-high-reliability
This commentary describes high reliability …
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psnet.ahrq.gov/node/38315/psn-pdf
October 24, 2018 - Defusing Disruptive Behavior. A Workbook for Health
Care Leaders.
October 24, 2018
Oakbrook, IL: Joint Commission Resources; 2007. ISBN: 9781599400846.
https://psnet.ahrq.gov/issue/defusing-disruptive-behavior-workbook-health-care-leaders
This workbook includes background on disruptive behaviors and provides tools…
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psnet.ahrq.gov/node/37035/psn-pdf
June 10, 2018 - Ongoing, preventable fatal events with fentanyl
transdermal patches are alarming!
June 10, 2018
ISMP Medication Safety Alert! Acute Care Edition. June 28, 2007;12:1-3.
https://psnet.ahrq.gov/issue/ongoing-preventable-fatal-events-fentanyl-transdermal-patches-are-alarming
This article discusses inappropriate prescr…
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psnet.ahrq.gov/node/36073/psn-pdf
September 28, 2010 - Patient safety: through the eyes of your peers.
September 28, 2010
Bry K, Stettner B, Marks J. Patient safety: through the eyes of your peers. Nurs Manage. 2006;37(6):20-24.
https://psnet.ahrq.gov/issue/patient-safety-through-eyes-your-peers
The authors present a peer review model for analyzing nursing behavior and…
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psnet.ahrq.gov/node/36603/psn-pdf
November 01, 2012 - Technological methods used to prevent errors aren't
infallible.
November 1, 2012
Santell JP. Technological methods used to prevent errors aren't infallible. Mater Manag Health Care.
2006;15(12):26-30.
https://psnet.ahrq.gov/issue/technological-methods-used-prevent-errors-arent-infallible
The author discusses the …