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psnet.ahrq.gov/node/44265/psn-pdf
January 22, 2016 - How surgical trainees handle catastrophic errors: a
qualitative study.
January 22, 2016
Balogun JA, Bramall AN, Bernstein M. How Surgical Trainees Handle Catastrophic Errors: A Qualitative
Study. J Surg Educ. 2015;72(6):1179-84. doi:10.1016/j.jsurg.2015.05.003.
https://psnet.ahrq.gov/issue/how-surgical-trainees-ha…
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psnet.ahrq.gov/node/42579/psn-pdf
November 18, 2013 - Surgical safety checklist compliance: a job done poorly!
November 18, 2013
Sparks EA, Wehbe-Janek H, Johnson RL, et al. Surgical Safety Checklist compliance: a job done poorly!. J
Am Coll Surg. 2013;217(5):867-73.e1-3. doi:10.1016/j.jamcollsurg.2013.07.393.
https://psnet.ahrq.gov/issue/surgical-safety-checklist-com…
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psnet.ahrq.gov/node/47011/psn-pdf
June 20, 2018 - Standardized Competencies for Parenteral Nutrition
Administration: the ASPEN Model.
June 20, 2018
Guenter P, Worthington P, Ayers P, et al. Standardized Competencies for Parenteral Nutrition
Administration: The ASPEN Model. Nutr Clin Pract. 2018;33(2):295-304. doi:10.1002/ncp.10055.
https://psnet.ahrq.gov/issue/st…
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psnet.ahrq.gov/node/61097/psn-pdf
November 04, 2020 - Obstetrician-gynecologist views of pregnancy-related
medication safety.
November 4, 2020
SteelFisher GK, Hero JO, Caporello HL, et al. Obstetrician-gynecologist views of pregnancy-related
medication safety. J Womens Health (Larchmt). 2020;29(8):1113-1121. doi:10.1089/jwh.2019.8007.
https://psnet.ahrq.gov/issue/obs…
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psnet.ahrq.gov/node/47473/psn-pdf
December 05, 2018 - Holding out for an apology.
December 5, 2018
Holding out for an apology. BMJ. 2018;363:k3033. doi:10.1136/bmj.k3033.
https://psnet.ahrq.gov/issue/holding-out-apology
Patients who experience care complications are vulnerable to psychological consequences that can affect
their relationship with their clinical teams.…
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psnet.ahrq.gov/node/837695/psn-pdf
July 20, 2022 - Narrowing the mindware gap in medicine.
July 20, 2022
Croskerry P. Narrowing the mindware gap in medicine. Diagnosis (Berl). 2022;9(2):176-183.
doi:10.1515/dx-2020-0128.
https://psnet.ahrq.gov/issue/narrowing-mindware-gap-medicine
In dual process thinking, Type 1 decisions are made rapidly, but can result in diagn…
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psnet.ahrq.gov/node/48005/psn-pdf
May 08, 2019 - Why your doctor's white coat can be a threat to your
health.
May 8, 2019
Haun N, Hooper-Lane C, Safdar N. Healthcare Personnel Attire and Devices as Fomites: A Systematic
Review. Infect Control Hosp Epidemiol. 2016;37(11):1367-1373.
https://psnet.ahrq.gov/issue/why-your-doctors-white-coat-can-be-threat-your-health…
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psnet.ahrq.gov/node/50921/psn-pdf
February 19, 2020 - How chaos at chain pharmacies is putting patients at risk.
February 19, 2020
Gabler E. New York Times. January 31, 2020.
https://psnet.ahrq.gov/issue/how-chaos-chain-pharmacies-putting-patients-risk
Pharmacists are instrumental to safe medication use in the ambulatory setting. This news story discusses
f…
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psnet.ahrq.gov/node/47681/psn-pdf
January 30, 2019 - Infection prevention in the operating room anesthesia
work area.
January 30, 2019
Munoz-Price S, Bowdle A, Johnston L, et al. Infection prevention in the operating room anesthesia work
area. Infect Control Hosp Epidemiol. 2018:1-17. doi:10.1017/ice.2018.303.
https://psnet.ahrq.gov/issue/infection-prevention-operat…
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psnet.ahrq.gov/node/866406/psn-pdf
July 31, 2024 - Impact of a daily huddle on safety in perioperative
services.
July 31, 2024
Tuyishime H, Claure RE, Balakrishnan K, et al. Impact of a daily huddle on safety in perioperative services.
Jt Comm J Qual Patient Saf. 2024;50(9):678-683. doi:10.1016/j.jcjq.2024.04.012.
https://psnet.ahrq.gov/issue/impact-daily-huddle-s…
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psnet.ahrq.gov/node/45318/psn-pdf
September 28, 2016 - Medication errors in outpatient pediatrics.
September 28, 2016
Berrier K. Medication Errors in Outpatient Pediatrics. MCN Am J Matern Child Nurs. 2016;41(5):280-6.
doi:10.1097/NMC.0000000000000261.
https://psnet.ahrq.gov/issue/medication-errors-outpatient-pediatrics
Medication errors occur in various care environm…
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psnet.ahrq.gov/node/47623/psn-pdf
February 06, 2019 - Diagnostic heuristics in dermatology—part 1 and part 2.
February 6, 2019
Lowenstein EJ, Sidlow R. Cognitive and visual diagnostic errors in dermatology: part 1 and part 2. J
Dermatol. 2018;179(6):1263-1276. doi:10.1111/bjd.16932.
https://psnet.ahrq.gov/issue/diagnostic-heuristics-dermatology-part-1-and-part-2
Cogn…
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psnet.ahrq.gov/node/46374/psn-pdf
August 30, 2017 - Structured patient handoffs: the movement toward
adverse event reduction in the perioperative unit.
August 30, 2017
Hamilton WL.
https://psnet.ahrq.gov/issue/structured-patient-handoffs-movement-toward-adverse-event-reduction-
perioperative-unit
Miscommunication during care transitions can contribute to medical e…
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psnet.ahrq.gov/node/47122/psn-pdf
June 13, 2018 - Intravenous chemotherapy compounding errors in a
follow-up pan-Canadian observational study.
June 13, 2018
Gilbert RE, Kozak MC, Dobish RB, et al. Intravenous Chemotherapy Compounding Errors in a Follow-Up
Pan-Canadian Observational Study. J Oncol Pract. 2018;14(5):e295-e303. doi:10.1200/JOP.17.00007.
https://psne…
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psnet.ahrq.gov/node/45952/psn-pdf
May 31, 2017 - Surgeon, Heal Thyself: Optimising Surgical Performance
by Managing Stress.
May 31, 2017
Shiralkar U. Boca Raton, FL: CRC Press; 2017. ISBN: 9781498724036.
https://psnet.ahrq.gov/issue/surgeon-heal-thyself-optimising-surgical-performance-managing-stress
Stress, information overload, and high-risk decisions are prev…
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psnet.ahrq.gov/node/46263/psn-pdf
July 12, 2017 - The texting debate: beneficial means of communication or
safety and security risk?
July 12, 2017
ISMP Medication Safety Alert! Acute Care Edition. June 29, 2017;16:1-5.
https://psnet.ahrq.gov/issue/texting-debate-beneficial-means-communication-or-safety-and-security-risk
Adopting new technologies in health care ca…
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psnet.ahrq.gov/node/837000/psn-pdf
May 06, 2022 - Lessons Learned about Human Fallibility, System Design,
and Justice in the Aftermath of a Fatal Medication Error.
May 6, 2022
Institute for Safe Medication Practices and the Just Culture Company. May 6, 2022.
https://psnet.ahrq.gov/issue/lessons-learned-about-human-fallibility-system-design-and-justice-aftermath-
…
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psnet.ahrq.gov/node/855099/psn-pdf
November 08, 2023 - Doctors wrestle with A.I. in patient care, citing lax
oversight.
November 8, 2023
Jewett C. New York Times. October 30, 2023
https://psnet.ahrq.gov/issue/doctors-wrestle-ai-patient-care-citing-lax-oversight
US Food and Drug Administration regulation and review is noted as having gaps in process that can affect
pa…
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psnet.ahrq.gov/node/842759/psn-pdf
January 18, 2023 - Cognitive aids in the management of clinical
emergencies: a systematic review.
January 18, 2023
Greig PR, Zolger D, Onwochei DN, et al. Cognitive aids in the management of clinical emergencies: a
systematic review. Anaesthesia. 2023;78(3):343-355. doi:10.1111/anae.15939.
https://psnet.ahrq.gov/issue/cognitive-aids…
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psnet.ahrq.gov/node/50870/psn-pdf
February 05, 2020 - A survey of outpatient internal medicine clinician
perceptions of diagnostic error.
February 5, 2020
Matulis JC, Kok SN, Dankbar EC, et al. A survey of outpatient Internal Medicine clinician perceptions of
diagnostic error. Diagnosis. 2020;7(2):107-114. doi:10.1515/dx-2019-0070.
https://psnet.ahrq.gov/issue/survey…