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psnet.ahrq.gov/node/35712/psn-pdf
August 27, 2010 - ACOG Committee Opinion #464: patient safety in the
surgical environment.
August 27, 2010
Committee Opinion No. 464: Patient Safety in the Surgical Environment. Obstetrics & Gynecology.
2010;116(3). doi:10.1097/aog.0b013e3181f69b22.
https://psnet.ahrq.gov/issue/acog-committee-opinion-464-patient-safety-surgical-env…
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psnet.ahrq.gov/node/40510/psn-pdf
June 08, 2011 - Causes of near misses: perceptions of perioperative
nurses.
June 8, 2011
Cohoon B. Causes of near misses: perceptions of perioperative nurses. AORN J. 2011;93(5):551-65.
doi:10.1016/j.aorn.2010.02.017.
https://psnet.ahrq.gov/issue/causes-near-misses-perceptions-perioperative-nurses
Perioperative nurses implicated…
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psnet.ahrq.gov/node/37360/psn-pdf
January 05, 2012 - Building accountability through patient safety
organizations.
January 5, 2012
Ross J. Building accountability through patient safety organizations. J Perianesth Nurs. 2007;22(5):346-8.
https://psnet.ahrq.gov/issue/building-accountability-through-patient-safety-organizations
This commentary introduces the Patient S…
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psnet.ahrq.gov/node/40609/psn-pdf
July 13, 2011 - Human reliability analysis: a critique and review for
managers.
July 13, 2011
French S, Bedford T, Pollard SJT, et al. Human reliability analysis: A critique and review for managers. Saf
Sci. 2011;49(6). doi:10.1016/j.ssci.2011.02.008.
https://psnet.ahrq.gov/issue/human-reliability-analysis-critique-and-review-man…
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psnet.ahrq.gov/node/42366/psn-pdf
June 19, 2013 - Quality, patient safety, and the cardiac surgical team.
June 19, 2013
Martinez EA. Quality, Patient Safety, and the Cardiac Surgical Team. Anesthesiol Clin. 2013;31(2):249-
268. doi:10.1016/j.anclin.2013.01.004.
https://psnet.ahrq.gov/issue/quality-patient-safety-and-cardiac-surgical-team
This review discusses the…
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psnet.ahrq.gov/node/41991/psn-pdf
January 23, 2013 - Handovers from the OR to the ICU.
January 23, 2013
Bonifacio AS, Segall N, Barbeito A, et al. Handovers from the OR to the ICU. Int Anesthesiol Clin.
2013;51(1):43-61. doi:10.1097/AIA.0b013e31826f2b0e.
https://psnet.ahrq.gov/issue/handovers-or-icu
This commentary discusses concerns associated with patient transfer…
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psnet.ahrq.gov/node/39221/psn-pdf
January 13, 2010 - The effects of stress and coping on surgical performance
during simulations.
January 13, 2010
Wetzel CM, Black SA, Hanna GB, et al. The effects of stress and coping on surgical performance during
simulations. Ann Surg. 2010;251(1):171-6. doi:10.1097/SLA.0b013e3181b3b2be.
https://psnet.ahrq.gov/issue/effects-stress…
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psnet.ahrq.gov/node/37821/psn-pdf
June 11, 2008 - Full work analysis of resident work hours.
June 11, 2008
Dassinger MS, Eubanks JW, Langham MR. Full work analysis of resident work hours. J Surg Res.
2008;147(2):178-81. doi:10.1016/j.jss.2008.03.010.
https://psnet.ahrq.gov/issue/full-work-analysis-resident-work-hours
A time-motion study of surgical residents foun…
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psnet.ahrq.gov/node/42408/psn-pdf
July 10, 2013 - Non-technical Skills and the Future of Teamwork in
Healthcare Settings.
July 10, 2013
Sevdalis N. London, UK: The Health Foundation; June 2013.
https://psnet.ahrq.gov/issue/non-technical-skills-and-future-teamwork-healthcare-settings
Highlighting the value of teamwork in delivering safe care, this report describes…
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psnet.ahrq.gov/node/36328/psn-pdf
January 02, 2011 - Challenges ahead in technology training: a report on the
training initiative of the Committee on Technology.
January 2, 2011
Olympio MA; Reinke B; Abramovich A.
https://psnet.ahrq.gov/issue/challenges-ahead-technology-training-report-training-initiative-committee-
technology
The authors describe the complexity of…
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psnet.ahrq.gov/node/37672/psn-pdf
April 09, 2008 - An observational study of laterality errors in a sample of
clinical records.
April 9, 2008
Elghrably I, Fraser SG. An observational study of laterality errors in a sample of clinical records. Eye
(Lond). 2008;22(3):340-3.
https://psnet.ahrq.gov/issue/observational-study-laterality-errors-sample-clinical-records
C…
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psnet.ahrq.gov/node/41469/psn-pdf
October 19, 2012 - Deconstructing intraoperative communication failures.
October 19, 2012
Hu Y-Y, Arriaga AF, Peyre S, et al. Deconstructing intraoperative communication failures. J Surg Res.
2012;177(1):37-42. doi:10.1016/j.jss.2012.04.029.
https://psnet.ahrq.gov/issue/deconstructing-intraoperative-communication-failures
Video reco…
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psnet.ahrq.gov/node/42785/psn-pdf
January 01, 2014 - The effects of safety checklists in medicine: a systematic
review.
December 19, 2013
Thomassen Ø, Storesund A, Søfteland E, et al. The effects of safety checklists in medicine: a systematic
review. Acta Anaesthesiol Scand. 2014;58(1):5-18. doi:10.1111/aas.12207.
https://psnet.ahrq.gov/issue/effects-safety-checklis…
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psnet.ahrq.gov/node/35689/psn-pdf
December 31, 2014 - Error reduction through team leadership: applying
aviation's CRM model in the OR.
December 31, 2014
Healy GB, Barker J, Madonna G. Error reduction through team leadership: applying aviation's CRM model
in the OR. Bull Am Coll Surg. 2006;91(2):10-5.
https://psnet.ahrq.gov/issue/error-reduction-through-team-leadersh…
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psnet.ahrq.gov/node/49429/psn-pdf
January 01, 2004 - Ruptured Heterotopic Pregnancy
January 1, 2004
Cedars MI. Ruptured Heterotopic Pregnancy. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/ruptured-heterotopic-pregnancy
The Case
A 43-year-old woman, gravida 3 para 2, presented at 16 weeks' gestational age with abdominal pain. Her
current pregnancy was the r…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.33_slideshow.ppt
October 01, 2003 - Spotlight Case [MONTH] 2003
Spotlight Case October 2003
Hemivulvectomy:
Wrong Side Removed
Source and Credits
This presentation is based on the Oct. 2003
AHRQ WebM&M Spotlight Case in OB/GYN
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Charles Vin…
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psnet.ahrq.gov/node/41936/psn-pdf
December 19, 2012 - A multiple-drawer medication layout problem in
automated dispensing cabinets.
December 19, 2012
Pazour JA, Meller RD. A multiple-drawer medication layout problem in automated dispensing cabinets.
Health Care Manag Sci. 2012;15(4). doi:10.1007/s10729-012-9197-8.
https://psnet.ahrq.gov/issue/multiple-drawer-medicati…
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psnet.ahrq.gov/node/46644/psn-pdf
June 20, 2018 - The Science of Teamwork.
June 20, 2018
McDaniel SH, Salas E, eds. Am Psychol. 2018;73:305-600.
https://psnet.ahrq.gov/issue/science-teamwork
Effective teams are core to safe practice in a wide range of work environments. This special issue explores
team psychology with an emphasis on high-risk industries such as s…
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psnet.ahrq.gov/node/36175/psn-pdf
September 29, 2010 - Discovering healthcare cognition: the use of cognitive
artifacts to reveal cognitive work.
September 29, 2010
Nemeth CP, O’Connor M, Klock PA, et al. Discovering Healthcare Cognition: The Use of Cognitive Artifacts
to Reveal Cognitive Work. Organization Studies. 2006;27(7). doi:10.1177/0170840606065708.
https://ps…
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psnet.ahrq.gov/node/35949/psn-pdf
May 24, 2006 - Implementation of patient safety initiatives in US
hospitals.
May 24, 2006
McFadden KL, Stock GN, Gowen CR. Implementation of patient safety initiatives in US hospitals. Int J
Oper Prod Manag. 2006;26(3):326-347. doi:10.1108/01443570610651052.
https://psnet.ahrq.gov/issue/implementation-patient-safety-initiatives-…