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psnet.ahrq.gov/issue/effect-lawsuits-professional-well-being-and-medical-error-rates-among-orthopaedic-surgeons
May 18, 2022 - Study
Effect of lawsuits on professional well-being and medical error rates among orthopaedic surgeons.
Citation Text:
Adelani MA, Hong Z, Miller AN. Effect of lawsuits on professional well-being and medical error rates among orthopaedic surgeons. J Am Acad Orthop Surg. 2023;31(16):893-9…
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psnet.ahrq.gov/issue/implementation-science-neglected-opportunity-accelerate-improvements-safety-and-quality
February 14, 2018 - Review
Implementation science: a neglected opportunity to accelerate improvements in the safety and quality of surgical care.
Citation Text:
Hull L, Athanasiou T, Russ S. Implementation Science: A Neglected Opportunity to Accelerate Improvements in the Safety and Quality of Surgical Care…
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psnet.ahrq.gov/issue/common-general-surgical-never-events-analysis-nhs-england-never-event-data
April 14, 2021 - Study
Common general surgical never events: analysis of NHS England never event data.
Citation Text:
Omar I, Singhal R, Wilson M, et al. Common general surgical never events: analysis of NHS England never event data. Int J Qual Health Care. 2021;33(1):mzab045. doi:10.1093/intqhc/mzab045.…
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psnet.ahrq.gov/node/40753/psn-pdf
September 07, 2011 - Preoperative surgical briefings do not delay operating
room start times and are popular with surgical team
members.
September 7, 2011
Ali M, Osborne A, Bethune R, et al. Preoperative surgical briefings do not delay operating room start times
and are popular with surgical team members. J Patient Saf. 2011;7(3):139-…
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psnet.ahrq.gov/node/43393/psn-pdf
July 30, 2014 - Effectiveness of the surgical safety checklist in correcting
errors: a literature review applying Reason's Swiss
cheese model.
July 30, 2014
Collins SJ, Newhouse R, Porter J, et al. Effectiveness of the surgical safety checklist in correcting errors: a
literature review applying Reason's Swiss cheese model. AORN J…
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psnet.ahrq.gov/node/41316/psn-pdf
February 05, 2014 - Organ donor's surgery death sparks questions.
February 5, 2014
Cohen E. CNN. April 9, 2012.
https://psnet.ahrq.gov/issue/organ-donors-surgery-death-sparks-questions
This news article reports on errors that contributed to the death of a live organ donor and describes
regulations to protect organ donors' safety.
ht…
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psnet.ahrq.gov/node/38458/psn-pdf
March 04, 2009 - In just a flash, simple surgery can turn deadly.
March 4, 2009
Landro L.
https://psnet.ahrq.gov/issue/just-flash-simple-surgery-can-turn-deadly
This newspaper article discusses increasing concerns over potential burn injuries in the hospital setting and
reports on efforts to raise awareness of the dangers and prom…
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psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx
Spotlight
A Missed Bowel Perforation – the Importance of
Diagnostic Reasoning
Source and Credits
• This presentation is based on the September 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/web…
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psnet.ahrq.gov/node/866261/psn-pdf
July 10, 2024 - Missed Compartment Syndrome after Steep Lithotomy
Position for Laparoscopic Gynecological Surgery
July 10, 2024
Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic
Gynecological Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/missed-compartment-syndrome…
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psnet.ahrq.gov/node/49485/psn-pdf
August 29, 2024 - Blind Spot
June 1, 2005
Lee LA. Blind Spot. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/blind-spot
The Case
A 36-year-old woman with no significant past medical history underwent right nephrectomy in the left lateral
position. The surgery was uncomplicated—her blood pressures intraoperatively were withi…
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psnet.ahrq.gov/topics-0
March 03, 2025 - Topics
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Featured Topics in Patient Safety
Updated Date: March 3, 2025
…
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psnet.ahrq.gov/clinical-areas
March 24, 2025 - Clinical Areas
Scroll down to search or browse using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the nurse care or medical specialty, featured in the resources.
Latest by Clinical Areas
In Conversation with Edwin Boudreaux about S…
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psnet.ahrq.gov/node/42294/psn-pdf
May 22, 2013 - Misdiagnosis is more common than drug errors or wrong-
site surgery.
May 22, 2013
Boodman SG. Washington Post. May 6, 2013.
https://psnet.ahrq.gov/issue/misdiagnosis-more-common-drug-errors-or-wrong-site-surgery
This newspaper article discusses the pervasive problem of diagnostic errors and reveals insights from
…
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psnet.ahrq.gov/issue/safe-site-invasive-procedure-non-operating-room
December 07, 2022 - Commentary
Safe Site Invasive Procedure—Non-Operating Room.
Citation Text:
Safe Site Invasive Procedure—Non-Operating Room. Institute for Clinical Systems Improvement.
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psnet.ahrq.gov/issue/impact-professionalism-safe-surgical-care
January 23, 2017 - Commentary
The impact of professionalism on safe surgical care.
Citation Text:
Whittemore A, Surgery NES for V. The impact of professionalism on safe surgical care. J Vasc Surg. 2007;45(2):415-9.
Copy Citation
Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/issue/administrative-issues-ensure-safe-anesthesia-care-office-based-setting
March 27, 2019 - Review
Administrative issues to ensure safe anesthesia care in the office-based setting.
Citation Text:
Gaulton TG, Shapiro FE, Urman RD. Administrative issues to ensure safe anesthesia care in the office-based setting. Curr Opin Anaesthesiol. 2013;26(6):692-7. doi:10.1097/ACO.00000000…
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psnet.ahrq.gov/issue/handoff-protocol-cardiovascular-operating-room-cardiac-icu-associated-improvements-care
December 09, 2020 - Study
A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period.
Citation Text:
Kaufmnan J, Twite M, Barrett C, et al. A handoff protocol from the cardiovascular operating room to cardiac I…
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psnet.ahrq.gov/issue/association-coworker-reports-about-unprofessional-behavior-surgeons-surgical-complications
June 27, 2018 - Study
Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients.
Citation Text:
Cooper WO, Spain DA, Guillamondegui O, et al. Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complication…
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psnet.ahrq.gov/issue/personal-protective-equipment-ppe-surgeons-during-covid-19-pandemic-systematic-review
September 23, 2020 - Review
Emerging Classic
Personal protective equipment (PPE) for surgeons during COVID-19 pandemic: a systematic review of availability, usage, and rationing.
Citation Text:
Jessop ZM, Dobbs TD, Ali SR, et al. Personal protective equipment for surgeons during COV…
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psnet.ahrq.gov/issue/outcome-differences-between-surgeons-performing-first-and-subsequent-coronary-artery-bypass
May 25, 2022 - Study
Outcome differences between surgeons performing first and subsequent coronary artery bypass grafting procedures in a day: a retrospective comparative cohort study.
Citation Text:
Zhang D, Gu D, Rao C, et al. Outcome differences between surgeons performing first and subsequent coron…