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psnet.ahrq.gov/issue/building-safer-systems-through-critical-occurrence-reviews-nine-years-learning
July 05, 2017 - Study
Building safer systems through critical occurrence reviews: nine years of learning.
Citation Text:
Stevens P, Campbell J, Urmson L, et al. Building safer systems through critical occurrence reviews: nine years of learning. Healthc Q. 2010;13 Spec No:74-80.
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psnet.ahrq.gov/issue/why-it-so-hard-talk-about-overuse-pediatrics-and-why-it-matters
March 04, 2020 - Commentary
Why it is so hard to talk about overuse in pediatrics and why it matters.
Citation Text:
Ralston SL, Schroeder AR. Why It Is So Hard to Talk About Overuse in Pediatrics and Why It Matters. JAMA Pediatr. 2017;171(10):931-932. doi:10.1001/jamapediatrics.2017.2239.
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psnet.ahrq.gov/issue/sensemaking-patient-safety-risks-and-hazards
March 03, 2011 - Commentary
Sensemaking of patient safety risks and hazards.
Citation Text:
Battles J, Dixon NM, Borotkanics RJ, et al. Sensemaking of patient safety risks and hazards. Health Serv Res. 2006;41(4 Pt 2):1555-1575.
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psnet.ahrq.gov/issue/creating-culture-caregiver-support
May 18, 2022 - Newspaper/Magazine Article
Creating a culture of caregiver support.
Citation Text:
Gold KJ, Andrew LB, Goldman EB, et al. “I would never want to have a mental health diagnosis on my record”: A survey of female physicians on mental health diagnosis, treatment, and reporting. General Hospi…
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psnet.ahrq.gov/issue/reviewing-methodologically-disparate-data-practical-guide-patient-safety-research-field
April 24, 2018 - Commentary
Reviewing methodologically disparate data: a practical guide for the patient safety research field.
Citation Text:
Brown KF, Long SJ, Athanasiou T, et al. Reviewing methodologically disparate data: a practical guide for the patient safety research field. J Eval Clin Pract. 2…
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psnet.ahrq.gov/issue/diagnostic-error-national-incident-reporting-system-uk
February 15, 2013 - Study
Diagnostic error in a national incident reporting system in the UK.
Citation Text:
Sevdalis N, Jacklin R, Arora S, et al. Diagnostic error in a national incident reporting system in the UK. J Eval Clin Pract. 2010;16(6):1276-81. doi:10.1111/j.1365-2753.2009.01328.x.
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psnet.ahrq.gov/issue/improving-communication-and-resolution-following-adverse-events-using-patient-created
September 01, 2018 - Study
Improving communication and resolution following adverse events using a patient-created simulation exercise.
Citation Text:
Gallagher TH, Etchegaray J, Bergstedt B, et al. Improving Communication and Resolution Following Adverse Events Using a Patient-Created Simulation Exercise. H…
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psnet.ahrq.gov/issue/do-team-processes-really-have-effect-clinical-performance-systematic-literature-review
November 13, 2019 - Review
Do team processes really have an effect on clinical performance? A systematic literature review.
Citation Text:
Schmutz J, Manser T. Do team processes really have an effect on clinical performance? A systematic literature review. Br J Anaesth. 2013;110(4). doi:10.1093/bja/aes513.…
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psnet.ahrq.gov/issue/changing-conversations-teaching-safety-and-quality-residency-training
January 02, 2017 - Study
Changing conversations: teaching safety and quality in residency training.
Citation Text:
Voss JD, May NB, Schorling JB, et al. Changing conversations: teaching safety and quality in residency training. Acad Med. 2008;83(11):1080-7. doi:10.1097/ACM.0b013e31818927f8.
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psnet.ahrq.gov/issue/we-are-going-name-names-and-call-you-out-improving-team-academic-operating-room-environment
September 23, 2020 - Study
We are going to name names and call you out! Improving the team in the academic operating room environment.
Citation Text:
Bodor R, Nguyen BJ, Broder K. We Are Going to Name Names and Call You Out! Improving the Team in the Academic Operating Room Environment. Ann Plast Surg. 2017;…
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psnet.ahrq.gov/issue/beyond-medical-record-other-modes-error-acknowledgment
August 03, 2009 - Study
Beyond the medical record: other modes of error acknowledgment.
Citation Text:
Rosenthal M, Cornett PL, Sutcliffe K, et al. Beyond the medical record: other modes of error acknowledgment. J Gen Intern Med. 2005;20(5):404-9.
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psnet.ahrq.gov/issue/impact-performance-obstacles-intensive-care-nurses-workload-perceived-quality-and-safety-care
March 11, 2020 - Study
Impact of performance obstacles on intensive care nurses' workload, perceived quality and safety of care, and quality of working life.
Citation Text:
Gurses AP, Carayon P, Wall M. Impact of performance obstacles on intensive care nurses' workload, perceived quality and safety of …
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psnet.ahrq.gov/issue/medication-administration-variances-and-after-implementation-computerized-physician-order
July 19, 2023 - Study
Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit.
Citation Text:
Taylor JA, Loan LA, Kamara J, et al. Medication administration variances before and after implementation of computerized phy…
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psnet.ahrq.gov/issue/time-motion-study-pediatric-emergency-department-and-after-computer-physician-order-entry
October 19, 2022 - Study
Time motion study in a pediatric emergency department before and after computer physician order entry.
Citation Text:
Yen K, Shane EL, Pawar SS, et al. Time motion study in a pediatric emergency department before and after computer physician order entry. Ann Emerg Med. 2009;53(4)…
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psnet.ahrq.gov/issue/prescribing-errors-pediatric-emergency-department
December 04, 2016 - Study
Prescribing errors in a pediatric emergency department.
Citation Text:
Rinke ML, Moon M, Clark J, et al. Prescribing errors in a pediatric emergency department. Pediatr Emerg Care. 2008;24(1):1-8. doi:10.1097/pec.0b013e31815f6f6c.
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psnet.ahrq.gov/issue/natural-lifespan-safety-policy-violations-and-system-migration-anaesthesia
June 22, 2009 - Study
The natural lifespan of a safety policy: violations and system migration in anaesthesia.
Citation Text:
Maurice G de S, Auroy Y, Vincent CA, et al. The natural lifespan of a safety policy: violations and system migration in anaesthesia. Qual Saf Health Care. 2010;19(4):327-31. doi:…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - judgment and errors in technique occurred, and the attending surgeon was ultimately responsible for the outcome … Approach to Improving Patient Safety
Errors in both judgement and technique led to this adverse outcome … understandings about the allowable number and location of cannulation attempts, could also have improved the outcome … Following these best practices could have resulted in a much better outcome for the patient in this case
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psnet.ahrq.gov/web-mm/pregnant-danger
January 12, 2011 - e.g., CT scan) might have detected the aortic dissection before the discharge and subsequent tragic outcome … The mother and fetus in this case suffered a tragic outcome at a hospital that appeared to lack a structured … It is unclear whether the outcome would have been different elsewhere. … Aortic dissection in pregnancy: analysis of risk factors and outcome.
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
Luckily, this case has a good outcome … student or practicing team level through critical incident root cause analysis and
http://www.acgme.org/outcome … Available at:
http://www.acgme.org/outcome/. Accessed September 27, 2007.
13. … cmd=retrieve&db=pubmed&dopt=abstract&list_uids=9032162
http://www.acgme.org/outcome/
http://www.ama-assn.org
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psnet.ahrq.gov/issue/probability-error-diagnosis-conjunction-fallacy-among-beginning-medical-students
June 21, 2017 - April 3, 2019
Outcome differences between surgeons performing first and subsequent coronary