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psnet.ahrq.gov/web-mm/standard-deviations
January 01, 2006 - SPOTLIGHT CASE
Standard Deviations
Citation Text:
Sabin JE. Standard Deviations. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - Failure to Rescue the Mother
Citation Text:
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/periodic-issue/periodic-issue-469
December 31, 2024 - system, the selection and scope of investigations, the methodology and investigation approach, and the skill
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psnet.ahrq.gov/curated-library/patient-and-family-engagement-long-term-care
April 10, 2024 - of avoidable problems in long term care and suggests prevention strategies that center on workforce skill
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - Root Cause Analysis Gone Wrong
Citation Text:
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/49491/psn-pdf
September 01, 2005 - Simulation offers a potential solution for resuscitation skill acquisition and retention. … shows objective improvements in ACLS proficiency, subjective
ratings of both confidence in one’s own skill … The five-stage model of adult skill acquisition. Bull Sci Technol Soc. 2004;24:177-181.
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psnet.ahrq.gov/web-mm/time-death
January 03, 2017 - Simulation offers a potential solution for resuscitation skill acquisition and retention. … shows objective improvements in ACLS proficiency, subjective ratings of both confidence in one’s own skill … The five-stage model of adult skill acquisition. Bull Sci Technol Soc. 2004;24:177-181. 5.
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psnet.ahrq.gov/issue/learning-adverse-events-and-near-misses
January 15, 2020 - Commentary
Learning from adverse events and near misses.
Citation Text:
Greenberg CC. Learning from adverse events and near misses. J Gastrointest Surg. 2009;13(1):3-5. doi:10.1007/s11605-008-0693-6.
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psnet.ahrq.gov/issue/clinical-cognition-and-biomedical-informatics-issues-patient-safety
September 04, 2024 - Commentary
Clinical cognition and biomedical informatics: issues of patient safety.
Citation Text:
Patel VL, Currie L. Clinical cognition and biomedical informatics: Issues of patient safety. Int J Med Inform. 2005;74(11-12). doi:10.1016/j.ijmedinf.2005.07.009.
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psnet.ahrq.gov/issue/first-do-no-harm-lost-concept-medical-education
December 01, 2004 - Commentary
Is "first do no harm" a lost concept in medical education?
Citation Text:
O'Leary D. Is "first do no harm" a lost concept in medical education. MedGenMed. 2006;8(3):77.
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psnet.ahrq.gov/issue/cutting-out-human-error
February 25, 2009 - Commentary
Cutting out human error.
Citation Text:
Feinmann J. Cutting out human error. BMJ. 2008;337:a2370. doi:10.1136/bmj.a2370.
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psnet.ahrq.gov/issue/error-reduction-through-team-leadership-applying-aviations-crm-model-or
September 25, 2013 - Commentary
Error reduction through team leadership: applying aviation's CRM model in the OR.
Citation Text:
Healy GB, Barker J, Madonna G. Error reduction through team leadership: applying aviation's CRM model in the OR. Bull Am Coll Surg. 2006;91(2):10-5.
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psnet.ahrq.gov/issue/medically-induced-trauma-support-services-mitss
December 07, 2016 - Newspaper/Magazine Article
Medically Induced Trauma Support Services (MITSS).
Citation Text:
Medically Induced Trauma Support Services (MITSS). Tobin WN. Patient Safety Quality Healthcare. May/June 2013.
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psnet.ahrq.gov/issue/stepping-out-further-shadows-disclosure-harmful-radiologic-errors-patients
April 21, 2011 - Commentary
Stepping out further from the shadows: disclosure of harmful radiologic errors to patients.
Citation Text:
Brown SD, Lehman CD, Truog RD, et al. Stepping Out Further from the Shadows: Disclosure of Harmful Radiologic Errors to Patients. Radiology. 2012;262(2):381-386. doi:10…
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psnet.ahrq.gov/issue/health-literacy-and-communication-quality-health-care-organizations
November 26, 2014 - Study
Health literacy and communication quality in health care organizations.
Citation Text:
Wynia M, Osborn CY. Health literacy and communication quality in health care organizations. J Health Commun. 2010;15 Suppl 2:102-15. doi:10.1080/10810730.2010.499981.
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psnet.ahrq.gov/issue/breaking-mould-patient-safety
June 20, 2011 - Commentary
Breaking the mould in patient safety.
Citation Text:
Degos L, Amalberti R, Bacou J, et al. Breaking the mould in patient safety. BMJ. 2009;338:b2585. doi:10.1136/bmj.b2585.
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psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
December 01, 2010 - not to admit guilt when we don't have it or fault when we don't have it—if we can learn that human skill … Disclosure is also a skill for life, not a skill just for work. … This is a skill for when you crash the car, you overdraw the checking account. … This is a skill for all of those things, not just when you've made a medical error.
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psnet.ahrq.gov/issue/uncovering-risks-anticancer-therapy-through-incident-report-analysis-using-newly-developed
January 29, 2018 - Almost Fatal Medication Error
June 1, 2018
Clinical scenarios: enhancing the skill
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psnet.ahrq.gov/issue/safety-culture-and-complications-after-bariatric-surgery
August 02, 2015 - August 2, 2015
Surgical skill and complication rates after bariatric surgery.
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psnet.ahrq.gov/issue/sensitivity-routine-system-reporting-patient-safety-incidents-nhs-hospital-retrospective
March 28, 2012 - February 15, 2010
Surgical skill is predicted by the ability to detect errors.