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psnet.ahrq.gov/issue/communication-skills-and-error-intensive-care-unit
May 06, 2009 - May 6, 2009
Team situation awareness and the anticipation of patient progress during
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psnet.ahrq.gov/issue/how-series-errors-led-recurrent-hypoglycemia
April 23, 2014 - July 2, 2019
Use of design thinking and human factors approach to improve situation awareness
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psnet.ahrq.gov/node/47568/psn-pdf
March 06, 2019 - Trends in anesthesia-related liability and lessons learned.
March 6, 2019
Mora JC, Kaye AD, Romankowski ML, et al. Trends in Anesthesia-Related Liability and Lessons Learned.
Adv Anesth. 2018;36(1):231-249. doi:10.1016/j.aan.2018.07.009.
https://psnet.ahrq.gov/issue/trends-anesthesia-related-liability-and-lessons-l…
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psnet.ahrq.gov/node/33810/psn-pdf
June 01, 2016 - We use SBAR (situation, background, assessment, recommendation) as our
methodology for nurse-to-physician
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psnet.ahrq.gov/node/836715/psn-pdf
March 09, 2022 - Non-technical skills in surgery during the COVID-19
pandemic: an observational study.
March 9, 2022
Etheridge JC, Moyal-Smith R, Sonnay Y, et al. Non-technical skills in surgery during the COVID-19
pandemic: an observational study. Int J Surg. 2022;98:106210. doi:10.1016/j.ijsu.2021.106210.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/73587/psn-pdf
August 11, 2021 - Effects of a brief team training program on surgical
teams' nontechnical skills: an interrupted time-series
study.
August 11, 2021
Gillespie BM, Harbeck EL, Kang E, et al. Effects of a brief team training program on surgical teams'
nontechnical skills: an interrupted time-series study. J Patient Saf. 2021;17(5):e4…
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psnet.ahrq.gov/node/60317/psn-pdf
May 13, 2020 - The nurse's experience of decision-making processes in
missed nursing care: a qualitative study.
May 13, 2020
Abdelhadi N, Drach?Zahavy A, Srulovici E. The nurse’s experience of decision?making processes in
missed nursing care: a qualitative study. J Adv Nurs. 2020;76(8):2161-2170. doi:10.1111/jan.14387.
https://p…
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psnet.ahrq.gov/node/850170/psn-pdf
June 07, 2023 - A scoping review of distributed cognition in acute care
clinical decision-making.
June 7, 2023
Wilson E, Daniel M, Rao A, et al. A scoping review of distributed cognition in acute care clinical decision-
making. Diagnosis (Berl). 2023;10(2):68-88. doi:10.1515/dx-2022-0095.
https://psnet.ahrq.gov/issue/scoping-revi…
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psnet.ahrq.gov/node/73464/psn-pdf
July 07, 2021 - Errors in breast imaging: how to reduce errors and
promote a safety environment.
July 7, 2021
Sivarajah R, Dinh ML, Chetlen A. Errors in breast imaging: how to reduce errors and promote a safety
environment. J Breast Imaging. 2021;3(2):221-230. doi:10.1093/jbi/wbaa118.
https://psnet.ahrq.gov/issue/errors-breast-im…
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psnet.ahrq.gov/node/50937/psn-pdf
February 26, 2020 - Emergency intubation of children outside of the operating
room.
February 26, 2020
Long E, Barrett MJ, Peters C, et al. Emergency intubation of children outside of the operating room.
Paediatr Anaesth. 2020;30(3):319-330. doi:10.1111/pan.13784.
https://psnet.ahrq.gov/issue/emergency-intubation-children-outside-oper…
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psnet.ahrq.gov/periodic-issue/periodic-issue-345
May 16, 2022 - June 8, 2022 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, a…
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psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
September 27, 2023 - Due to the urgency of the situation, the primary nurse overrode the automated dispensing unit and mistakenly
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psnet.ahrq.gov/node/73684/psn-pdf
September 08, 2021 - Provider bias in prescribing opioid analgesics: a study of
electronic medical records at a hospital emergency
department.
September 8, 2021
Keister LA, Stecher C, Aronson B, et al. Provider bias in prescribing opioid analgesics: a study of electronic
medical records at a hospital emergency department. BMC Public H…
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psnet.ahrq.gov/node/44764/psn-pdf
February 10, 2016 - Human factors—recognising and minimising errors in our
day to day practice.
February 10, 2016
Green B, Tsiroyannis C, Brennan PA. Human factors--recognising and minimising errors in our day to day
practice. Oral Dis. 2016;22(1):19-22. doi:10.1111/odi.12384.
https://psnet.ahrq.gov/issue/human-factors-recognising-an…
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psnet.ahrq.gov/issue/perioperative-medication-errors-uncovering-risk-behind-drapes
March 27, 2018 - Beyond the surgical safety checklist: using intraoperative handoff to facilitate team situation
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psnet.ahrq.gov/issue/barriers-and-facilitators-nursing-handoffs-recommendations-redesign
January 22, 2016 - March 4, 2011
Understanding situation awareness in nursing work: a hybrid concept analysis
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psnet.ahrq.gov/issue/identifying-causes-adverse-events-detected-automated-trigger-tool-through-depth-analysis
October 05, 2011 - December 2, 2014
Improving situation awareness to reduce unrecognized clinical deterioration
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psnet.ahrq.gov/issue/new-frontier-healthcare-risk-management-working-reduce-avoidable-patient-suffering
September 26, 2012 - August 20, 2014
Discrepant perceptions of communication, teamwork and situation awareness
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psnet.ahrq.gov/issue/team-working-intensive-care-current-evidence-and-future-endeavors
April 24, 2018 - May 6, 2009
Team situation awareness and the anticipation of patient progress during
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psnet.ahrq.gov/issue/quality-and-safety-intensive-care-unit
January 19, 2011 - August 21, 2013
Team situation awareness and the anticipation of patient progress during