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psnet.ahrq.gov/node/836754/psn-pdf
March 16, 2022 - State of science: evolving perspectives on ‘human error’.
March 16, 2022
Read GJM, Shorrock S, Walker GH, et al. State of science: evolving perspectives on ‘human error’.
Ergonomics. 2021;64(9):1091-1114. doi:10.1080/00140139.2021.1953615.
https://psnet.ahrq.gov/issue/state-science-evolving-perspectives-human-error…
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psnet.ahrq.gov/node/39235/psn-pdf
March 05, 2010 - An examination of technical efficiency, quality, and
patient safety in acute care nursing units.
March 5, 2010
Mark BA, Jones CB, Lindley L, et al. An examination of technical efficiency, quality, and patient safety in
acute care nursing units. Policy Polit Nurs Pract. 2009;10(3):180-6. doi:10.1177/1527154409346322…
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psnet.ahrq.gov/node/50826/psn-pdf
January 22, 2020 - Health Informatics, Healthcare Quality and Safety, and
Healthcare Simulation: the New Triad to Advance
Healthcare Operations
January 22, 2020
Feldman SS, Brazil V, Zengul FD, et al, eds. Health Syst (Basingstoke). 2019;8(3):153-227.
https://psnet.ahrq.gov/issue/health-informatics-healthcare-quality-and-safety-and-…
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psnet.ahrq.gov/node/37913/psn-pdf
July 31, 2008 - Reliability of a revised NOTECHS scale for use in surgical
teams.
July 31, 2008
Sevdalis N, Davis R, Koutantji M, et al. Reliability of a revised NOTECHS scale for use in surgical teams.
Am J Surg. 2008;196(2):184-90. doi:10.1016/j.amjsurg.2007.08.070.
https://psnet.ahrq.gov/issue/reliability-revised-notechs-scale…
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psnet.ahrq.gov/node/41418/psn-pdf
June 15, 2012 - Speaking across the drapes: communication strategies of
anesthesiologists and obstetricians during a simulated
maternal crisis.
June 15, 2012
Minehart RD, Pian-Smith MCM, Walzer TB, et al. Speaking across the drapes: communication strategies of
anesthesiologists and obstetricians during a simulated maternal crisis…
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psnet.ahrq.gov/node/45229/psn-pdf
July 13, 2016 - The WakeWings journey: creating a patient safety
program.
July 13, 2016
Mills E. The WakeWings Journey: Creating a Patient Safety Program. AORN J. 2016;103(6):636-9.
doi:10.1016/j.aorn.2016.04.004.
https://psnet.ahrq.gov/issue/wakewings-journey-creating-patient-safety-program
Successful and sustainable implementa…
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psnet.ahrq.gov/node/41156/psn-pdf
March 02, 2012 - The implementation of a perioperative checklist increases
patients' perioperative safety and staff satisfaction.
March 2, 2012
Böhmer AB, Wappler F, Tinschmann T, et al. The implementation of a perioperative checklist increases
patients' perioperative safety and staff satisfaction. Acta Anaesthesiol Scand. 2012;56(…
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psnet.ahrq.gov/node/35394/psn-pdf
April 06, 2011 - Getting teams to talk: development and pilot
implementation of a checklist to promote
interprofessional communication in the OR.
April 6, 2011
Lingard L, Espin S, Rubin B, et al. Getting teams to talk: development and pilot implementation of a
checklist to promote interprofessional communication in the OR. Qual Sa…
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psnet.ahrq.gov/node/39844/psn-pdf
November 02, 2010 - Safety through redundancy: a case study of in-hospital
patient transfers.
November 2, 2010
Ong M-S, Coiera E. Safety through redundancy: a case study of in-hospital patient transfers. Qual Saf
Health Care. 2010;19(5):e32. doi:10.1136/qshc.2009.035972.
https://psnet.ahrq.gov/issue/safety-through-redundancy-case-stu…
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psnet.ahrq.gov/node/39177/psn-pdf
May 04, 2010 - The impact of organisational and individual factors on
team communication in surgery: a qualitative study.
May 4, 2010
Gillespie BM, Chaboyer W, Longbottom P, et al. The impact of organisational and individual factors on
team communication in surgery: a qualitative study. Int J Nurs Stud. 2010;47(6):732-41.
doi:10…
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psnet.ahrq.gov/node/40328/psn-pdf
September 27, 2016 - Critical phase distractions in anaesthesia and the sterile
cockpit concept.
September 27, 2016
Broom MA, Capek AL, Carachi P, et al. Critical phase distractions in anaesthesia and the sterile cockpit
concept. Anaesthesia. 2011;66(3):175-179. doi:10.1111/j.1365-2044.2011.06623.x.
https://psnet.ahrq.gov/issue/critic…
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psnet.ahrq.gov/node/41074/psn-pdf
January 18, 2012 - Patients count on it: an initiative to reduce incorrect
counts and prevent retained surgical items.
January 18, 2012
Norton EK, Martin C, Micheli AJ. Patients Count on It: An Initiative to Reduce Incorrect Counts and Prevent
Retained Surgical Items. AORN J. 2011;95(1). doi:10.1016/j.aorn.2011.06.007.
https://psnet…
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psnet.ahrq.gov/node/41134/psn-pdf
July 06, 2012 - Differential impact of a crew resource management
program according to professional specialty.
July 6, 2012
Suva D, Haller G, Lübbeke A, et al. Differential impact of a crew resource management program according
to professional specialty. Am J Med Qual. 2012;27(4):313-20. doi:10.1177/1062860611423805.
https://psne…
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psnet.ahrq.gov/node/44387/psn-pdf
August 19, 2015 - Simulation in Surgical Training and Practice.
August 19, 2015
Brown KM, Paige JT, eds. Surg Clin North Am. 2015;95:695-918.
https://psnet.ahrq.gov/issue/simulation-surgical-training-and-practice
Simulation training is being used more broadly as an educational approach in health care. Articles in this
special issue…
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psnet.ahrq.gov/node/45476/psn-pdf
September 21, 2016 - Use of a surgical safety checklist to improve team
communication.
September 21, 2016
Cabral RA, Eggenberger T, Keller K, et al. Use of a surgical safety checklist to improve team
communication. AORN J. 2016;104(3):206-216. doi:10.1016/j.aorn.2016.06.019.
https://psnet.ahrq.gov/issue/use-surgical-safety-checklist-i…
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psnet.ahrq.gov/node/38630/psn-pdf
May 13, 2009 - Seasoned surgeons assessed in a laparoscopic surgical
crisis.
May 13, 2009
Powers K, Rehrig ST, Schwaitzberg SD, et al. Seasoned surgeons assessed in a laparoscopic surgical
crisis. J Gastrointest Surg. 2009;13(5):994-1003. doi:10.1007/s11605-009-0802-1.
https://psnet.ahrq.gov/issue/seasoned-surgeons-assessed-lapa…
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psnet.ahrq.gov/node/40966/psn-pdf
November 30, 2011 - Toward safer practice in otology: a report on 15 years of
clinical negligence claims.
November 30, 2011
Mathew R, Asimacopoulos E, Valentine P. Toward safer practice in otology: a report on 15 years of clinical
negligence claims. Laryngoscope. 2011;121(10):2214-9. doi:10.1002/lary.22136.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/43036/psn-pdf
March 27, 2014 - Redesigning hospital alarms for patient safety: alarmed
and potentially dangerous.
March 27, 2014
Chopra V, McMahon LF. Redesigning hospital alarms for patient safety: alarmed and potentially
dangerous. JAMA. 2014;311(12):1199-200. doi:10.1001/jama.2014.710.
https://psnet.ahrq.gov/issue/redesigning-hospital-alarms…
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psnet.ahrq.gov/node/43522/psn-pdf
October 15, 2014 - A model of disruptive surgeon behavior in the
perioperative environment.
October 15, 2014
Cochran A, Elder WB. A model of disruptive surgeon behavior in the perioperative environment. J Am Coll
Surg. 2014;219(3):390-8. doi:10.1016/j.jamcollsurg.2014.05.011.
https://psnet.ahrq.gov/issue/model-disruptive-surgeon-beh…
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psnet.ahrq.gov/node/50577/psn-pdf
October 23, 2019 - Medicare's Oversight of Ambulatory Surgery Centers
Report.
October 23, 2019
Washington, DC: Office of the Inspector General; September 2019. Report No. OEI-01-15-00400.
https://psnet.ahrq.gov/issue/medicares-oversight-ambulatory-surgery-centers-report
Ambulatory surgery centers (ASC) play an increasing role in com…