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psnet.ahrq.gov/node/73857/psn-pdf
September 22, 2021 - A theoretical model of flow disruptions for the anesthesia
team during cardiovascular surgery.
September 22, 2021
Boquet A, Cohen T, Diljohn F, et al. A theoretical model of flow disruptions for the anesthesia team during
cardiovascular surgery. J Patient Saf. 2021;17(6):e534-e539. doi:10.1097/pts.0000000000000406.…
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psnet.ahrq.gov/node/47242/psn-pdf
January 01, 2021 - "It matters what I think, not what you say": scientific
evidence for a medical error disclosure competence
(MEDC) model.
October 10, 2018
Hannawa AF, Frankel RM. "It Matters What I Think, Not What You Say": Scientific Evidence for a Medical
Error Disclosure Competence (MEDC) Model. J Patient Saf. 2021;17(8):e1130-…
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psnet.ahrq.gov/node/836826/psn-pdf
March 30, 2022 - Pediatric trainee perspectives on the decision to disclose
medical errors.
March 30, 2022
Lin M, Horwitz LI, Gross RS, et al. Pediatric trainee perspectives on the decision to disclose medical errors.
J Patient Saf. 2022;18(2):e470-e476. doi:10.1097/pts.0000000000000848.
https://psnet.ahrq.gov/issue/pediatric-trai…
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psnet.ahrq.gov/node/39090/psn-pdf
November 11, 2009 - Nurse reports of adverse events during sedation
procedures at a pediatric hospital.
November 11, 2009
Lightdale JR, Mahoney LB, Fredette ME, et al. Nurse reports of adverse events during sedation procedures
at a pediatric hospital. J Perianesth Nurs. 2009;24(5):300-6. doi:10.1016/j.jopan.2009.07.004.
https://psnet…
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psnet.ahrq.gov/node/72603/psn-pdf
December 23, 2020 - Telemedicine as a medical examination tool during the
Covid-19 emergency: the experience of the onco-
haematology center of Tor Vergata Hospital in Rome.
December 23, 2020
Postorino M, Treglia M, Giammatteo J, et al. Telemedicine as a medical examination tool during the Covid-
19 emergency: the experience of the o…
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psnet.ahrq.gov/node/72577/psn-pdf
December 16, 2020 - Identifying trigger concepts to screen emergency
department visits for diagnostic errors.
December 16, 2020
Mahajan P, Pai C-W, Cosby KS, et al. Identifying trigger concepts to screen emergency department visits
for diagnostic errors. Diagnosis (Berl). 2021;8(3):340-346. doi:10.1515/dx-2020-0122.
https://psnet.ahr…
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psnet.ahrq.gov/node/60601/psn-pdf
June 17, 2020 - Prevalence, types, and sources of bullying reported by US
general surgery residents in 2019.
June 17, 2020
Zhang LM, Ellis RJ, Ma M, et al. Prevalence, types, and sources of bullying reported by US general surgery
residents in 2019. JAMA. 2020;323(20):2093-2095. doi:10.1001/jama.2020.2901.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/60598/psn-pdf
June 17, 2020 - Associations of workflow disruptions in the operating
room with surgical outcomes: a systematic review and
narrative synthesis.
June 17, 2020
Koch A, Burns J, Catchpole K, et al. Associations of workflow disruptions in the operating room with
surgical outcomes: a systematic review and narrative synthesis. BMJ Qual…
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psnet.ahrq.gov/node/840140/psn-pdf
January 01, 2023 - Implementation of the I-PASS handoff program in diverse
clinical environments: a multicenter prospective
effectiveness implementation study.
November 16, 2022
Starmer AJ, Spector ND, O'Toole JK, et al. Implementation of the I?PASS handoff program in diverse
clinical environments: a multicenter prospective effectiv…
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psnet.ahrq.gov/node/36229/psn-pdf
October 19, 2010 - Learning from mistakes in New Zealand hospitals: what
else do we need besides "no-fault"?
October 19, 2010
Soleimani F. Learning from mistakes in New Zealand hospitals: what else do we need besides "no-fault"? N
Z Med J. 2006;119(1239):U2099.
https://psnet.ahrq.gov/issue/learning-mistakes-new-zealand-hospitals-wha…
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psnet.ahrq.gov/node/34981/psn-pdf
July 14, 2010 - Child-specific risk factors and patient safety.
July 14, 2010
Woods DM, Holl JL, Shonkoff JP, et al. J Patient Saf. 2005;1(1):17-22.
https://psnet.ahrq.gov/issue/child-specific-risk-factors-and-patient-safety
To discover factors that may contribute to a child’s risk for error during hospitalization, this study iden…
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psnet.ahrq.gov/node/43078/psn-pdf
June 03, 2014 - The value of autopsies in the era of high-tech medicine:
discrepant findings persist.
June 3, 2014
Kuijpers CCHJ, Fronczek J, van de Goot FRW, et al. The value of autopsies in the era of high-tech
medicine: discrepant findings persist. J Clin Pathol. 2014;67(6):512-9. doi:10.1136/jclinpath-2013-202122.
https://psn…
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psnet.ahrq.gov/node/37156/psn-pdf
October 06, 2011 - Preventable harm occurring to critically ill children.
October 6, 2011
Larsen G, Donaldson AE, Parker HB, et al. Preventable harm occurring to critically ill children. Pediatr Crit
Care Med. 2007;8(4):331-336.
https://psnet.ahrq.gov/issue/preventable-harm-occurring-critically-ill-children
This retrospective cohort…
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psnet.ahrq.gov/node/61064/psn-pdf
October 28, 2020 - Feasibility of patient-reported diagnostic errors following
emergency department discharge: a pilot study.
October 28, 2020
Gleason KT, Peterson SM, Dennison Himmelfarb CR, et al. Feasibility of patient-reported diagnostic errors
following emergency department discharge: a pilot study. Diagnosis (Berl). 2021;8(2):1…
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psnet.ahrq.gov/node/841141/psn-pdf
December 07, 2022 - Urgent referrals from primary care to dermatology for
lesions suspicious for skin cancer: patterns, outcomes,
and need for systems improvement.
December 7, 2022
Pagani K, Lukac D, Olbricht SM, et al. Urgent referrals from primary care to dermatology for lesions
suspicious for skin cancer: patterns, outcomes, and n…
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psnet.ahrq.gov/node/73663/psn-pdf
September 01, 2021 - Racial disparities in preventable adverse events attributed
to poor care coordination reported in a national study of
older US adults.
September 1, 2021
Pinheiro LC, Reshetnyak E, Safford MM, et al. Racial disparities in preventable adverse events attributed to
poor care coordination reported in a national study o…
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psnet.ahrq.gov/node/61092/psn-pdf
November 04, 2020 - Patient race and opioid misuse history influence provider
risk perceptions for future opioid-related problems.
November 4, 2020
Hirsh AT, Anastas TM, Miller MM, et al. Patient race and opioid misuse history influence provider risk
perceptions for future opioid-related problems. Am Psychol. 2020;75(6):784-795.
doi:…
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psnet.ahrq.gov/node/60276/psn-pdf
April 29, 2020 - Body of evidence: do autopsy findings impact medical
malpractice claim outcomes?
April 29, 2020
Gartland RM, Myers LC, Iorgulescu JB, et al. Body of evidence: do autopsy findings impact medical
malpractice claim outcomes? J Patient Saf. 2020;17(8):576-582. doi:10.1097/pts.0000000000000686.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/846446/psn-pdf
March 22, 2023 - The accuracy of the Global Trigger Tool is higher for the
identification of adverse events of greater harm: a
diagnostic test study.
March 22, 2023
Moraes SM, Ferrari TCA, Beleigoli A. The accuracy of the Global Trigger Tool is higher for the identification
of adverse events of greater harm: a diagnostic test stud…
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psnet.ahrq.gov/node/73684/psn-pdf
September 08, 2021 - Provider bias in prescribing opioid analgesics: a study of
electronic medical records at a hospital emergency
department.
September 8, 2021
Keister LA, Stecher C, Aronson B, et al. Provider bias in prescribing opioid analgesics: a study of electronic
medical records at a hospital emergency department. BMC Public H…