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2781. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.37_slideshow.ppt
      November 01, 2003 - Spotlight Case [MONTH] 2003 Spotlight Case November 2003 The Missing Suction Tip Source and Credits This presentation is based on the Nov. 2003 AHRQ WebM&M Spotlight Case in Surgery See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Eric J. Thomas, MD,…

2782. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/862124/psn-pdf
      February 07, 2024 - The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: scale development and psychometric evaluation. February 7, 2024 Ali KJ, Goeschel CA, Eckroade MM, et al. The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: scale development and psychometric evaluation. Jt Comm J Qual Patient Saf. 2024;50(2):95…

2783. In response to “Getting to the Root of the Matter” (June 2005) | PSNet
      psnet.ahrq.gov/perspective/response-getting-root-matter-june-2005
      June 01, 2005 - In response to “Getting to the Root of the Matter” (June 2005) September 1, 2005  View more articles from the same authors. Citation Text: Grondin L, Saint S, Flanders S, et al. In response to “Getting to the Root of the Matter” (June 2005). PSNet [internet]. Rockv…

2784. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49838/psn-pdf
      August 01, 2018 - by the nurse in charge of the patient, and all the involved teams are expected to have at least one member

2785. Talking with Patients and Families about Medical Error: A Guide for Education and Practice. | PSNet
      psnet.ahrq.gov/issue/talking-patients-and-families-about-medical-error-guide-education-and-practice
      July 24, 2019 - Book/Report Talking with Patients and Families about Medical Error: A Guide for Education and Practice. Citation Text: Talking with Patients and Families about Medical Error: A Guide for Education and Practice. Truog RD, Browning DM, Johnson JA, Gallagher TH. Baltimore, MD: Johns Hopkins…

2786. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47622/psn-pdf
      April 24, 2019 - Consumer-directed technologies to improve medication management and safety. April 24, 2019 Andrade AQ, Roughead EE. Consumer-directed technologies to improve medication management and safety. Med J Aust. 2019;210(suppl 6):S24-S27. doi:10.5694/mja2.50029. https://psnet.ahrq.gov/issue/consumer-directed-technologies-…

2787. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61023/psn-pdf
      October 14, 2020 - Information concerning ICU patients’ families in the handover—the clinicians’ “game of whispers”: a qualitative study. October 14, 2020 Nygaard AM, Selnes Haugdahl H, Støre Brinchmann B, et al. Information concerning ICU patients’ families in the handover—the clinicians’ “game of whispers”: a qualitative study. J …

2788. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35807/psn-pdf
      August 19, 2017 - Teamwork in the operating theatre: cohesion or confusion? August 19, 2017 Undre S, Sevdalis N, Healey A, et al. Teamwork in the operating theatre: cohesion or confusion? J Eval Clin Pract. 2006;12(2):182-9. https://psnet.ahrq.gov/issue/teamwork-operating-theatre-cohesion-or-confusion The investigators interviewed…

2789. When Things Go Wrong: Voices of Patients and Families. | PSNet
      psnet.ahrq.gov/issue/when-things-go-wrong-voices-patients-and-families
      November 19, 2015 - Audiovisual When Things Go Wrong: Voices of Patients and Families. Citation Text: When Things Go Wrong: Voices of Patients and Families. CRICO/RMF; Harvard Risk Management Foundation Copy Citation Save Save to your library Print Download PDF Shar…

2790. Being open: communicating patient safety incidents with patients and their carers. | PSNet
      psnet.ahrq.gov/issue/being-open-communicating-patient-safety-incidents-patients-and-their-carers
      October 26, 2007 - Multi-use Website Being open: communicating patient safety incidents with patients and their carers. Citation Text: Being open: communicating patient safety incidents with patients and their carers. National Patient Safety Agency. Copy Citation Save Save to your l…

2791. Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention. | PSNet
      psnet.ahrq.gov/issue/patients-and-families-teachers-mixed-methods-assessment-collaborative-learning-model-medical
      July 12, 2017 - Study Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention. Citation Text: Langer T, Martinez W, Browning DM, et al. Patients and families as teachers: a mixed methods assessment of a collaborative lea…

2792. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41051/psn-pdf
      February 20, 2012 - What do patients and relatives know about problems and failures in care? February 20, 2012 Iedema R, Allen S, Britton K, et al. What do patients and relatives know about problems and failures in care? BMJ Qual Saf. 2012;21(3):198-205. doi:10.1136/bmjqs-2011-000100. https://psnet.ahrq.gov/issue/what-do-patients-and…

2793. An Untimely End Despite End-of-Life Care Planning | PSNet
      psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
      February 01, 2012 - by the nurse in charge of the patient, and all the involved teams are expected to have at least one member

2794. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42535/psn-pdf
      October 16, 2013 - Implementing an interprofessional patient safety learning initiative: insights from participants, project leads and steering committee members. October 16, 2013 Jeffs L, Abramovich IA, Hayes C, et al. Implementing an interprofessional patient safety learning initiative: insights from participants, project leads an…

2795. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40275/psn-pdf
      March 23, 2011 - Discrepant perceptions of communication, teamwork and situation awareness among surgical team members. March 23, 2011 Wauben LSGL, van Doorn CMD-, van Wijngaarden JDH, et al. Discrepant perceptions of communication, teamwork and situation awareness among surgical team members. Int J Qual Health Care. 2011;23(2):15…

2796. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49423/psn-pdf
      November 01, 2003 - The Missing Suction Tip November 1, 2003 Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained foreign bodies. Understand methods used to prevent and identify retained foreign bodies. Apprecia…

2797. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47555/psn-pdf
      November 14, 2018 - How one hospital improved patient safety in 10 minutes a day. November 14, 2018 van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018. https://psnet.ahrq.gov/issue/how-one-hospital-improved-patient-safety-10-minutes-day Aviation continues to provide inspiration for patient safety innovation. This commentar…

2798. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34839/psn-pdf
      April 06, 2011 - Communication failures in the operating room: an observational classification of recurrent types and effects. April 6, 2011 Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13(5):330-4. http…

2799. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45031/psn-pdf
      February 18, 2017 - Information transfer in multidisciplinary operating room teams: a simulation-based observational study. February 18, 2017 Cumin D, Skilton C, Weller J. Information transfer in multidisciplinary operating room teams: a simulation- based observational study. BMJ Qual Saf. 2017;26(3):209-216. doi:10.1136/bmjqs-2015-00…

2800. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42638/psn-pdf
      October 09, 2013 - Strengths and weaknesses of working with the Global Trigger Tool method for retrospective record review: focus group interviews with team members. October 9, 2013 Schildmeijer K, Nilsson L, Perk J, et al. Strengths and weaknesses of working with the Global Trigger Tool method for retrospective record review: focus…