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psnet.ahrq.gov/issue/surgical-site-infections-colon-surgery-patient-procedure-hospital-and-surgeon
February 19, 2020 - Study
Surgical site infections in colon surgery: the patient, the procedure, the hospital, and the surgeon.
Citation Text:
Hübner M, Diana M, Zanetti G, et al. Surgical site infections in colon surgery: the patient, the procedure, the hospital, and the surgeon. Arch Surg. 2011;146(11):…
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psnet.ahrq.gov/issue/extraneous-tissue-potential-source-diagnostic-error-surgical-pathology
October 27, 2010 - Study
Extraneous tissue a potential source for diagnostic error in surgical pathology.
Citation Text:
Layfield LJ, Witt BL, Metzger KG, et al. Extraneous tissue: a potential source for diagnostic error in surgical pathology. Am J Clin Pathol. 2011;136(5):767-72. doi:10.1309/AJCP4FFSBPHA…
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psnet.ahrq.gov/issue/look-alike-sound-alike-drugs-review-include-look-alike-packaging-additional-safety-check
March 24, 2021 - Study
Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check.
Citation Text:
McCoy LK. Look-alike, sound-alike drugs review: include look-alike packaging as an additional safety check. Jt Comm J Qual Patient Saf. 2005;31(1):47-53.
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psnet.ahrq.gov/issue/inadequate-preoperative-team-briefings-lead-more-intraoperative-adverse-events
June 07, 2023 - Study
Inadequate preoperative team briefings lead to more intraoperative adverse events.
Citation Text:
Phadnis J, Templeton-Ward O. Inadequate Preoperative Team Briefings Lead to More Intraoperative Adverse Events. J Patient Saf. 2018;14(2):82-86. doi:10.1097/PTS.0000000000000181.
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psnet.ahrq.gov/issue/intraoperative-communications-between-pathologists-and-surgeons-do-we-understand-each-other
June 28, 2023 - Study
Intraoperative communications between pathologists and surgeons: do we understand each other?
Citation Text:
Wiggett A, Fischer G. Intraoperative communications between pathologists and surgeons: do we understand each other? Arch Pathol Lab Med. 2023;147(8):933-939. doi:10.5858/arp…
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psnet.ahrq.gov/issue/complication-rates-weekends-and-weekdays-us-hospitals
August 31, 2011 - Study
Complication rates on weekends and weekdays in US hospitals.
Citation Text:
Bendavid E, Kaganova Y, Needleman J, et al. Complication rates on weekends and weekdays in US hospitals. Am J Med. 2007;120(5):422-8.
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psnet.ahrq.gov/issue/sleep-and-errors-group-australian-hospital-nurses-work-and-during-commute
February 14, 2024 - Study
Sleep and errors in a group of Australian hospital nurses at work and during the commute.
Citation Text:
Dorrian J, Tolley C, Lamond N, et al. Sleep and errors in a group of Australian hospital nurses at work and during the commute. Appl Ergon. 2008;39(5):605-13. doi:10.1016/…
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psnet.ahrq.gov/issue/opioid-medication-discontinuation-and-risk-adverse-opioid-related-health-care-events
November 16, 2022 - Study
Classic
Opioid medication discontinuation and risk of adverse opioid-related health care events.
Citation Text:
Mark TL, Parish W. Opioid medication discontinuation and risk of adverse opioid-related health care events. J Subst Abuse Treat. 2019;103:58-63.…
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psnet.ahrq.gov/issue/preventing-mistransfusions-evaluation-institutional-knowledge-and-response
June 06, 2018 - Study
Preventing mistransfusions: an evaluation of institutional knowledge and a response.
Citation Text:
MacDougall N, Dong F, Broussard L, et al. Preventing Mistransfusions: An Evaluation of Institutional Knowledge and a Response. Anesth Analg. 2018;126(1):247-251. doi:10.1213/ANE.0000…
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psnet.ahrq.gov/issue/artificial-intelligence-health-care-accountability-and-safety
December 20, 2023 - Commentary
Classic
Artificial intelligence in health care: accountability and safety.
Citation Text:
Habli I, Lawton T, Porter Z. Artificial intelligence in health care: accountability and safety. Bull World Health Organ. 2020;98(4):251-256. doi:10.2471/blt.19.2…
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psnet.ahrq.gov/issue/perspectives-patient-and-family-engagement-reduction-harm-forgotten-voice
December 01, 2011 - Study
Perspectives on patient and family engagement with reduction in harm: the forgotten voice.
Citation Text:
Schenk EC, Bryant RA, Van Son CR, et al. Perspectives on Patient and Family Engagement With Reduction in Harm: The Forgotten Voice. J Nurs Care Qual. 2019;34(1):73-79. doi:10.1…
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psnet.ahrq.gov/issue/situation-background-assessment-recommendation-sbar-communication-tool-handoff-health-care
March 03, 2021 - Review
Emerging Classic
Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care- a narrative review.
Citation Text:
Shahid S, Thomas S. Situation, background, assessment, recommendation (SBAR) communication tool for…
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psnet.ahrq.gov/issue/incoming-interns-recognize-inadequate-physical-examination-cause-patient-harm
July 20, 2022 - Study
Incoming interns recognize inadequate physical examination as a cause of patient harm.
Citation Text:
Russo S, Berg K, Davis JJ, et al. Incoming interns recognize inadequate physical examination as a cause of patient harm. J Med Educ Curric Dev. 2020;7:238212052092899. doi:10.1177/…
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psnet.ahrq.gov/issue/modes-failure-venous-thromboembolism-prophylaxis
October 19, 2022 - Study
Modes of failure in venous thromboembolism prophylaxis.
Citation Text:
Richie CD, Castle JT, Davis GA, et al. Modes of failure in venous thromboembolism prophylaxis. Angiology. 2022;73(8):712-715. doi:10.1177/00033197221083724.
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psnet.ahrq.gov/issue/guidelines-human-factors-critical-situations-2023
November 29, 2023 - Organizational Policy/Guidelines
Guidelines on Human Factors in Critical Situations 2023.
Citation Text:
Bijok B, Jaulin F, Picard J, et al. Guidelines on human factors in critical situations 2023. Anaesth Crit Care Pain Med. 2023;42(4):101262. doi:10.1016/j.accpm.2023.101262.
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psnet.ahrq.gov/issue/complexity-science-challenge-complexity-health-care
March 13, 2013 - Commentary
Classic
Complexity science: the challenge of complexity in health care.
Citation Text:
Plsek PE, Greenhalgh T. Complexity science: The challenge of complexity in health care. BMJ. 2001;323(7313):625-628.
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psnet.ahrq.gov/issue/practical-guide-failure-mode-and-effects-analysis-health-care-making-most-team-and-its
March 04, 2015 - Commentary
A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and its meetings.
Citation Text:
Ashley L, Armitage G, Neary M, et al. A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and its …
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psnet.ahrq.gov/issue/case-34-2010-65-year-old-woman-incorrect-operation-left-hand
March 13, 2013 - Commentary
Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand.
Citation Text:
Ring DC, Herndon JH, Meyer GS. Case records of The Massachusetts General Hospital: Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand. N Engl J Med. 201…
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psnet.ahrq.gov/issue/infrastructure-provide-safer-higher-quality-and-more-equitable-telehealth
February 12, 2020 - Commentary
An infrastructure to provide safer, higher quality, and more equitable telehealth.
Citation Text:
Kobeissi MM, Hickey JV. An infrastructure to provide safer, higher quality, and more equitable telehealth. Jt Comm J Qual Patient Saf. 2023;49(4):213-222. doi:10.1016/j.jcjq.2023.…
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psnet.ahrq.gov/issue/opportunities-diagnostic-improvement-among-pediatric-hospital-readmissions
August 30, 2023 - Study
Opportunities for diagnostic improvement among pediatric hospital readmissions.
Citation Text:
Congdon M, Rauch B, Carroll B, et al. Opportunities for diagnostic improvement among pediatric hospital readmissions. Hosp Pediatr. 2023;13(7):563-571. doi:10.1542/hpeds.2023-007157.
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