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psnet.ahrq.gov/sites/default/files/2020-04/spotlight-slides-wright-schiff.pdf
January 01, 2020 - Robert Wachter, MD
○ Spotlight Editor: Bradley Sharpe, MD
○ Managing Editor: Erin Hartman, MS
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Objectives
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psnet.ahrq.gov/issue/triggers-emergency-team-activation-multicenter-assessment
March 05, 2010 - Study
Triggers for emergency team activation: a multicenter assessment.
Citation Text:
Chen J, Bellomo R, Hillman K, et al. Triggers for emergency team activation: a multicenter assessment. J Crit Care. 2010;25(2):359.e1-7. doi:10.1016/j.jcrc.2009.12.011.
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psnet.ahrq.gov/issue/application-engineering-problem-solving-methodology-address-persistent-problems-patient
March 18, 2020 - Study
Application of an engineering problem-solving methodology to address persistent problems in patient safety: a case study on retained surgical sponges after surgery.
Citation Text:
Anderson DE, Watts B. Application of an engineering problem-solving methodology to address persistent…
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psnet.ahrq.gov/web-mm/missed-appendicitis
March 13, 2013 - Case Objectives
Appreciate the variable presentations of appendicitis
List complications of missed … PubMedId RIS
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - Case Objectives
Understand the role of communication failures in medical errors and preventable adverse … PubMedId RIS
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - Case Objectives State how frequently physicians care for family or relatives. … PubMedId RIS
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psnet.ahrq.gov/issue/qualitative-content-analysis-retained-surgical-items-learning-root-cause-analysis
December 06, 2023 - Study
A qualitative content analysis of retained surgical items: learning from root cause analysis investigations.
Citation Text:
Hibbert PD, Thomas MJW, Deakin A, et al. A qualitative content analysis of retained surgical items: learning from root cause analysis investigations. Int J Qu…
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psnet.ahrq.gov/issue/risk-factors-retained-surgical-items-meta-analysis-and-proposed-risk-stratification-system
January 18, 2013 - Study
Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system.
Citation Text:
Moffatt-Bruce SD, Cook CH, Steinberg SM, et al. Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. J Surg Res. 2014;190(…
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psnet.ahrq.gov/issue/prevalence-and-characteristics-interruptions-and-distractions-during-surgical-counts
March 09, 2016 - Study
Prevalence and characteristics of interruptions and distractions during surgical counts.
Citation Text:
Bubric KA, Biesbroek SL, Laberge JC, et al. Prevalence and characteristics of interruptions and distractions during surgical counts. Jt Comm J Qual Patient Saf. 2021;47(9):556-56…
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psnet.ahrq.gov/issue/ai-radiographic-covid-19-detection-selects-shortcuts-over-signal
May 13, 2020 - Study
AI for radiographic COVID-19 detection selects shortcuts over signal.
Citation Text:
DeGrave AJ, Janizek JD, Lee S-I. AI for radiographic COVID-19 detection selects shortcuts over signal. Nat Mach Intell. 2021;3:610–619. doi:10.1038/s42256-021-00338-7.
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psnet.ahrq.gov/issue/association-between-professional-burnout-and-engagement-patient-safety-culture-and-outcomes
October 28, 2020 - Review
The association between professional burnout and engagement with patient safety culture and outcomes: a systematic review.
Citation Text:
Mossburg SE, Himmelfarb CD. The Association Between Professional Burnout and Engagement With Patient Safety Culture and Outcomes: A Systematic …
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psnet.ahrq.gov/issue/observational-study-conformity-yet-another-medical-learning-environment-conformity-preceptors
June 19, 2019 - Study
Observational study of conformity in yet another medical learning environment: conformity to preceptors during high-fidelity simulation.
Citation Text:
Beran T, Altabbaa G, Oddone Paolucci E. Observational study of conformity in yet another medical learning environment: conformity …
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psnet.ahrq.gov/issue/study-innovative-patient-safety-education
April 28, 2021 - Study
A study of innovative patient safety education.
Citation Text:
Smith SD, Henn P, Gaffney R, et al. A study of innovative patient safety education. Clin Teach. 2012;9(1):37-40. doi:10.1111/j.1743-498X.2011.00484.x.
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psnet.ahrq.gov/web-mm/dangerous-dialysis
June 12, 2024 - Case Objectives
List common errors that occur in dialysis units. … PubMedId RIS
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psnet.ahrq.gov/issue/developing-tool-assessing-competency-root-cause-analysis
May 01, 2014 - Study
Developing a tool for assessing competency in root cause analysis.
Citation Text:
Gupta P, Varkey P. Developing a tool for assessing competency in root cause analysis. Jt Comm J Qual Patient Saf. 2009;35(1):36-42.
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psnet.ahrq.gov/issue/safety-journal-lessons-learned-error-reporting-tool-stimulate-systems-thinking
January 21, 2019 - Study
The safety journal: lessons learned with an error reporting tool to stimulate systems thinking.
Citation Text:
Singh R, Naughton B, Singh A, et al. The Safety Journal. J Patient Saf. 2007;3(3):135-141. doi:10.1097/0b013e31814258db.
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psnet.ahrq.gov/issue/real-world-virtual-patient-simulation-improve-diagnostic-performance-through-deliberate
July 21, 2021 - Study
Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study.
Citation Text:
Kotwal S, Fanai M, Fu W, et al. Real-world virtual patient simulation to improve diagnostic performance through deliberate pra…
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psnet.ahrq.gov/node/60864/psn-pdf
August 31, 2020 - Safety Across The Board
August 31, 2020
Fitall E, Hall KK, Gale B. Safety Across The Board . PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/safety-across-board
Defining Safety Across the Board
Safety Across The Board (SAB) is a concept originating from the Centers for Medicare & Medicaid Services
(CMS…
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psnet.ahrq.gov/issue/using-radiofrequency-technology-prevent-retained-sponges-and-improve-patient-outcomes
November 25, 2020 - Study
Using radiofrequency technology to prevent retained sponges and improve patient outcomes.
Citation Text:
Primiano M, Sparks D, Murphy J, et al. Using radiofrequency technology to prevent retained sponges and improve patient outcomes. AORN J. 2020;112(4):345-352. doi:10.1002/aorn.13…
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psnet.ahrq.gov/node/865489/psn-pdf
April 03, 2024 - Safety is the preservation of value.
April 3, 2024
Vandeskog B. Safety is the preservation of value. J Safety Res. 2024;89:105-115.
doi:10.1016/j.jsr.2024.02.004.
https://psnet.ahrq.gov/issue/safety-preservation-value
Safety is at the heart of safety science, and yet “safety” lacks a consensus definition among saf…