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psnet.ahrq.gov/node/40453/psn-pdf
May 18, 2011 - A 60-year-old man with delayed care for a renal mass.
May 18, 2011
Schiff G. Medical error: a 60-year-old man with delayed care for a renal mass. JAMA. 2011;305(18):1890-
8. doi:10.1001/jama.2011.496.
https://psnet.ahrq.gov/issue/60-year-old-man-delayed-care-renal-mass
Clinical Crossroads is a popular series in th…
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psnet.ahrq.gov/node/49485/psn-pdf
August 29, 2024 - Blind Spot
June 1, 2005
Lee LA. Blind Spot. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/blind-spot
The Case
A 36-year-old woman with no significant past medical history underwent right nephrectomy in the left lateral
position. The surgery was uncomplicated—her blood pressures intraoperatively were withi…
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psnet.ahrq.gov/node/33584/psn-pdf
March 15, 2025 - In the operating room, poor communication has been directly linked to surgical complications
and has
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psnet.ahrq.gov/node/836976/psn-pdf
April 27, 2022 - The patient was subsequently taken to the operating room for exploration and debridement of
her injuries … After stabilization, she
was quickly transferred to the operating room (OR) for definitive management … patient with traumatic injuries was effectively
managed both acutely in the ED and definitively in the operating
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psnet.ahrq.gov/node/37908/psn-pdf
June 10, 2010 - Incidence and characteristics of potential and actual
retained foreign object events in surgical patients.
June 10, 2010
Cima RR, Kollengode A, Garnatz J, et al. Incidence and characteristics of potential and actual retained
foreign object events in surgical patients. J Am Coll Surg. 2008;207(1):80-7.
doi:10.1016/…
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psnet.ahrq.gov/node/37327/psn-pdf
March 03, 2011 - Patterns of technical error among surgical malpractice
claims: an analysis of strategies to prevent injury to
surgical patients.
March 3, 2011
Regenbogen SE, Greenberg CC, Studdert DM, et al. Patterns of technical error among surgical malpractice
claims: an analysis of strategies to prevent injury to surgical pati…
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psnet.ahrq.gov/issue/enhancing-safety-high-risk-operations-multilevel-analysis-role-mindful-organising-translating
January 26, 2022 - Study
Enhancing safety in high-risk operations: a multilevel analysis of the role of mindful organising in translating safety climate into individual safety behaviours.
Citation Text:
Renecle M, Curcuruto M, Gracia Lerín FJ, et al. Enhancing safety in high-risk operations: a multilevel a…
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psnet.ahrq.gov/issue/leadership-behavior-associations-domains-safety-culture-engagement-and-healthcare-worker-well
February 24, 2021 - Study
Leadership behavior associations with domains of safety culture, engagement, and healthcare worker well-being.
Citation Text:
Tawfik DS, Adair KC, Palassof S, et al. Leadership behavior associations with domains of safety culture, engagement, and healthcare worker well-being. Jt Co…
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psnet.ahrq.gov/node/40024/psn-pdf
December 21, 2014 - Risk factors and outcomes for foreign body left during a
procedure: analysis of 413 incidents after 1,946,831
operations in children.
December 21, 2014
Camp M, Chang DC, Zhang Y, et al. Risk factors and outcomes for foreign body left during a procedure:
analysis of 413 incidents after 1 946 831 operations in child…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
February 01, 2006 - educational activity, participants should be able to:
Provide an overview of transitions in continuously operating
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psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
January 01, 2022 - • The patient was subsequently taken to the operating room for
exploration and debridement of her … patient
with traumatic injuries was effectively managed both
acutely in the ED and definitively in the operating
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - Diffusion of Responsibility Leads to Danger
October 1, 2018
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
The Case
A 70-year-old man was sent to the emergency department (ED) from a nursing facility…
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psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
December 01, 2006 - An operating room has perhaps 15 different types of caregivers: anesthesiologists, OR nurses, surgeons … So when you compare an operating room to a cockpit, you come to an abrupt halt in the analogy when you … Yet, in the frenzy of a busy operating room, there undoubtedly needs to be some hierarchy, some leadership … impact of something, just like we've done with rapid response teams, medication reconciliation, or operating
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psnet.ahrq.gov/perspective/risk-management-and-patient-safety
December 01, 2010 - analyses and in separate studies.( 10 , 13 , 14 ) As a result, RMF has put in place interventions in the operating … A prospective study of patient safety in the operating room. Surgery. 2006;139:159-173. … Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating … April 21, 2015
Crisis checklists for the operating room: development and pilot testing
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psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
December 01, 2006 - An operating room has perhaps 15 different types of caregivers: anesthesiologists, OR nurses, surgeons … So when you compare an operating room to a cockpit, you come to an abrupt halt in the analogy when you … Yet, in the frenzy of a busy operating room, there undoubtedly needs to be some hierarchy, some leadership … impact of something, just like we've done with rapid response teams, medication reconciliation, or operating
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psnet.ahrq.gov/node/43042/psn-pdf
December 18, 2014 - Introduction of surgical safety checklists in Ontario,
Canada.
December 18, 2014
Urbach DR, Govindarajan A, Saskin R, et al. Introduction of Surgical Safety Checklists in Ontario, Canada.
New Engl J Med. 2014;370(11):1029-1038. doi:10.1056/nejmsa1308261.
https://psnet.ahrq.gov/issue/introduction-surgical-safety-ch…
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psnet.ahrq.gov/node/73554/psn-pdf
July 28, 2021 - must ensure the safe transition of the patient, as well as
maintaining the safety of bystanders by operating
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psnet.ahrq.gov/perspective/conversation-lucian-leape-md
June 12, 2019 - this in the most hierarchical, tradition-bound, ritualized, entrenched environment in medicine—the operating … The checklist is a tool for getting you to think about how to create a safe environment in an operating … March 1, 2011
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See More About The Topic
Operating Room
Physicians
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating … WebM&M Cases
To Dilute or Not Dilute: Drug Errors and Consequences in the Operating … View More
See More About The Topic
Hospitals
Intensive Care Units
Operating
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.33_slideshow.ppt
October 01, 2003 - Prevention of wrong-site surgery: sign, mark & x-ray (SMaX). http://www.spine.org/smax.cfm
Association of Operating