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psnet.ahrq.gov/node/45995/psn-pdf
May 24, 2017 - Patient Safety.
May 24, 2017
Todd DW, Bennett JD, eds. Oral Maxillofac Surg Clin North Am. 2017;29:121-244.
https://psnet.ahrq.gov/issue/patient-safety-13
Articles in this special issue provide insights into how human error can affect the safety of oral and
maxillofacial surgery, a primarily ambulatory environment…
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psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
August 21, 2015 - devices in health care is that providers are likely to have the device with them at all times and keep it operational
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psnet.ahrq.gov/node/848384/psn-pdf
May 03, 2023 - Roadmap to Health Care Safety for Massachusetts.
May 3, 2023
Massachusetts Healthcare Safety and Quality Consortium. Boston, MA: Betsy Lehman Center for Patient
Safety; April 2023.
https://psnet.ahrq.gov/issue/roadmap-health-care-safety-massachusetts
Collective engagement and focus are required to attain large sys…
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psnet.ahrq.gov/node/45003/psn-pdf
July 18, 2016 - Effect of surgical safety checklists on pediatric surgical
complications in Ontario.
July 18, 2016
O'Leary JD, Wijeysundera DN, Crawford MW. Effect of surgical safety checklists on pediatric surgical
complications in Ontario. CMAJ. 2016;188(9):E191-E198. doi:10.1503/cmaj.151333.
https://psnet.ahrq.gov/issue/effect…
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psnet.ahrq.gov/node/45139/psn-pdf
May 25, 2016 - Alarm management: promoting safety and establishing
guidelines.
May 25, 2016
Criscitelli T. Alarm Management: Promoting Safety and Establishing Guidelines. AORN J. 2016;103(5):518-
21. doi:10.1016/j.aorn.2016.03.008.
https://psnet.ahrq.gov/issue/alarm-management-promoting-safety-and-establishing-guidelines
Alarms…
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psnet.ahrq.gov/node/40897/psn-pdf
November 02, 2011 - Infrequent physician use of implantable cardioverter-
defibrillators risks patient safety.
November 2, 2011
Lyman S, Sedrakyan A, Do H, et al. Infrequent physician use of implantable cardioverter-defibrillators risks
patient safety. Heart. 2011;97(20):1655-60. doi:10.1136/hrt.2011.226282.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/72537/psn-pdf
December 02, 2020 - Automation failures and patient safety.
December 2, 2020
Ruskin KJ, Ruskin AC, O’Connor M. Automation failures and patient safety. Curr Opin Anaesthesiol.
2020;33(6):788-792. doi:10.1097/aco.0000000000000935.
https://psnet.ahrq.gov/issue/automation-failures-and-patient-safety
Task automation in medicine is a core …
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psnet.ahrq.gov/node/39295/psn-pdf
January 03, 2017 - The Veterans Affairs shift change physician-to-physician
handoff project.
January 3, 2017
Anderson J, Shroff D, Curtis A, et al. The Veterans Affairs shift change physician-to-physician handoff
project. Jt Comm J Qual Patient Saf. 2010;36(2):62-71.
https://psnet.ahrq.gov/issue/veterans-affairs-shift-change-physici…
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psnet.ahrq.gov/node/44728/psn-pdf
December 02, 2015 - Doctors debate safety of their white coats.
December 2, 2015
Butler DL, Major Y, Bearman G, et al. Transmission of nosocomial pathogens by white coats: an in-vitro
model. The Journal of hospital infection. 2010;75(2):137-8. doi:10.1016/j.jhin.2009.11.024.
https://psnet.ahrq.gov/issue/doctors-debate-safety-their-whi…
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psnet.ahrq.gov/node/47829/psn-pdf
March 27, 2019 - The impact of internal service quality on preventable
adverse events in hospitals.
March 27, 2019
Zheng S, Tucker AL, Ren ZJ, et al. The Impact of Internal Service Quality on Preventable Adverse Events
in Hospitals. Production Operations Manag. 2017;27(12):2201-2212. doi:10.1111/poms.12758.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/42720/psn-pdf
November 13, 2013 - Workplace bullying in the OR: results of a descriptive
study.
November 13, 2013
Chipps E, Stelmaschuk S, Albert NM, et al. Workplace Bullying in the OR: Results of a Descriptive Study.
AORN J. 2013;98(5). doi:10.1016/j.aorn.2013.08.015.
https://psnet.ahrq.gov/issue/workplace-bullying-or-results-descriptive-study
…
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psnet.ahrq.gov/node/41084/psn-pdf
January 25, 2012 - 'Skating on thin ice?' Consultant surgeon's contemporary
experience of adverse surgical events.
January 25, 2012
Skevington SM, Langdon JE, Giddins G. ‘Skating on thin ice?’ Consultant surgeon's contemporary
experience of adverse surgical events. Psychol Health Med. 2011;17(1).
doi:10.1080/13548506.2011.592841.
h…
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psnet.ahrq.gov/node/46885/psn-pdf
March 20, 2018 - Opioid prescribing patterns and complications in the
dermatology Medicare population.
March 20, 2018
Cao S, Karmouta R, Li DG, et al. Opioid Prescribing Patterns and Complications in the Dermatology
Medicare Population. JAMA Dermatol. 2018;154(3):317-322. doi:10.1001/jamadermatol.2017.5835.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/836720/psn-pdf
March 09, 2022 - Reliability, uncertainty and the management of error: new
perspectives in the COVID-19 era.
March 9, 2022
Schulman PR. Reliability, uncertainty and the management of error: new perspectives in the COVID?19
era. J Contingencies Crisis Manage. 2022;30(1):92-101. doi:10.1111/1468-5973.12356.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/41843/psn-pdf
November 21, 2012 - Sharing lessons learned to prevent incorrect surgery.
November 21, 2012
Neily J, Mills PD, Paull DE, et al. Sharing lessons learned to prevent incorrect surgery. Am Surg.
2012;78(11):1276-1280.
https://psnet.ahrq.gov/issue/sharing-lessons-learned-prevent-incorrect-surgery
The Veterans Affairs (VA) system has publi…
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psnet.ahrq.gov/node/42235/psn-pdf
June 03, 2013 - Surgical safety checklist: implementation in an
ambulatory surgical facility.
June 3, 2013
Morgan PJ, Cunningham L, Mitra S, et al. Surgical safety checklist: implementation in an ambulatory
surgical facility. Can J Anaesth. 2013;60(6):528-38. doi:10.1007/s12630-013-9916-8.
https://psnet.ahrq.gov/issue/surgical-sa…
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psnet.ahrq.gov/node/46174/psn-pdf
August 30, 2017 - Inpatients notes: sensemaking—fostering a shared
understanding in clinical teams.
August 30, 2017
Leykum LK, O'Leary KJ. Web Exclusives. Annals for Hospitalists Inpatient Notes - Sensemaking-Fostering
a Shared Understanding in Clinical Teams. Ann Intern Med. 2017;167(4):HO2-HO3. doi:10.7326/M17-
1829.
https://psn…
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psnet.ahrq.gov/node/43659/psn-pdf
November 05, 2014 - Intraoperative patient information handover between
anesthesia providers.
November 5, 2014
Choromanski D, Frederick J, McKelvey GM, et al. Intraoperative patient information handover between
anesthesia providers. J Biomed Res. 2014;28(5):383-387. doi:10.7555/JBR.28.20140001.
https://psnet.ahrq.gov/issue/intraopera…
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psnet.ahrq.gov/node/46508/psn-pdf
November 22, 2017 - The checklist: recognize limits, but harness its power.
November 22, 2017
Alspach JAG. The Checklist: Recognize Limits, but Harness Its Power. Crit Care Nurse. 2017;37(5):12-18.
doi:10.4037/ccn2017603.
https://psnet.ahrq.gov/issue/checklist-recognize-limits-harness-its-power
Checklists are used in various health c…
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psnet.ahrq.gov/node/39944/psn-pdf
October 20, 2010 - Increasing patient safety and surgical team
communication by using a count/time out board.
October 20, 2010
Edel EM. Increasing patient safety and surgical team communication by using a count/time out board.
AORN J. 2010;92(4):420-4. doi:10.1016/j.aorn.2010.03.013.
https://psnet.ahrq.gov/issue/increasing-patient-s…