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psnet.ahrq.gov/issue/patient-safety-anesthetic-practice
June 15, 2011 - Book/Report
Classic
Patient Safety in Anesthetic Practice.
Citation Text:
Patient Safety in Anesthetic Practice. Morell RC; Eichhorn JH, eds. New York: Churchill Livingstone, 1997. ISBN: 9780443076824.
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psnet.ahrq.gov/issue/when-bone-flap-hits-floor
March 12, 2025 - Study
When the bone flap hits the floor.
Citation Text:
Jankowitz BT, Kondziolka DS. When the bone flap hits the floor. Neurosurgery. 2006;59(3):585-90; discussion 585-90.
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psnet.ahrq.gov/issue/final-five-ascs-told-target-patient-safety
April 24, 2018 - Newspaper/Magazine Article
Final five: ASCs told to target patient safety.
Citation Text:
Rollins G. Final five: ASCs told to target patient safety. Hospitals & health networks. 2007;81(12):53-4, 56, 1.
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psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
July 01, 2003 - DNR in the OR and Afterwards
Citation Text:
Lo B. DNR in the OR and Afterwards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - first seven days after surgery
• In an observational study of nearly 46,000 consecutive orthopedic
surgeries
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psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
October 04, 2023 - Complex surgeries usually require at least two large-bore intravenous catheters, with 22-gauge catheters
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psnet.ahrq.gov/node/867429/psn-pdf
December 18, 2024 - Management of CSF Leaks After Elective Spine Surgery:
Routine Laminectomy Leads to Fatal Discitis and Sepsis
December 18, 2024
Castillo JA, Price R, Kim KD. Management of CSF Leaks After Elective Spine Surgery: Routine
Laminectomy Leads to Fatal Discitis and Sepsis. PSNet [internet]. 2024.
https://psnet.ahrq.gov/w…
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psnet.ahrq.gov/node/37453/psn-pdf
March 03, 2011 - Managing the prevention of retained surgical instruments:
what is the value of counting?
March 3, 2011
Egorova NN, Moskowitz A, Gelijns A, et al. Managing the prevention of retained surgical instruments: what
is the value of counting? Ann Surg. 2008;247(1):13-8.
https://psnet.ahrq.gov/issue/managing-prevention-ret…
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psnet.ahrq.gov/node/39314/psn-pdf
December 21, 2014 - Patient characteristics and the occurrence of never
events.
December 21, 2014
Fry DE, Pine M, Jones BL, et al. Patient characteristics and the occurrence of never events. Arch Surg.
2010;145(2):148-51. doi:10.1001/archsurg.2009.277.
https://psnet.ahrq.gov/issue/patient-characteristics-and-occurrence-never-events
…
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psnet.ahrq.gov/node/39570/psn-pdf
September 20, 2011 - Effect of a 19-item surgical safety checklist during urgent
operations in a global patient population.
September 20, 2011
Weiser TG, Haynes AB, Dziekan G, et al. Effect of A 19-Item Surgical Safety Checklist During Urgent
Operations in A Global Patient Population. Ann Surg. 2010;251(5). doi:10.1097/sla.0b013e3181d9…
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psnet.ahrq.gov/node/46820/psn-pdf
August 20, 2018 - Postsurgical prescriptions for opioid naive patients and
association with overdose and misuse: retrospective
cohort study.
August 20, 2018
Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with
overdose and misuse: retrospective cohort study. BMJ. 2018;360:j5790…
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psnet.ahrq.gov/node/47496/psn-pdf
June 15, 2019 - Fatal flaws in clinical decision making.
June 15, 2019
Davis SS, Babidge WJ, McCulloch GAJ, et al. Fatal flaws in clinical decision making. ANZ J Surg.
2019;89(6):764-768. doi:10.1111/ans.14955.
https://psnet.ahrq.gov/issue/fatal-flaws-clinical-decision-making
Clinical decision-making is a complex process affected…
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psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
September 25, 2019 - SPOTLIGHT CASE
Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery.
Citation Text:
Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.206_slideshow.ppt
October 01, 2009 - Spotlight Case
Spotlight Case
Difficult Encounters:
A CMO and CNO Respond
Source and Credits
This presentation is based on the October 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Ernie Ring, MD; Jane Hirsch, RN, MS
UCSF Medical Cen…
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psnet.ahrq.gov/issue/remote-video-auditing-real-time-feedback-academic-surgical-suite-improves-safety-and
August 04, 2021 - Study
Remote video auditing with real-time feedback in an academic surgical suite improves safety and efficiency metrics: a cluster randomised study.
Citation Text:
Overdyk FJ, Dowling O, Newman S, et al. Remote video auditing with real-time feedback in an academic surgical suite improve…
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psnet.ahrq.gov/web-mm/crossed-coverage
September 01, 2015 - She had already undergone multiple surgeries, including aortic valve replacement for which she was on
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psnet.ahrq.gov/node/33703/psn-pdf
November 01, 2010 - preventable events that compromise patient safety in the
acute-care setting, such as complications after surgeries
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psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - April 15, 2020
5 cataract surgeries, 5 people blinded: what went wrong?
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psnet.ahrq.gov/web-mm/too-tight-control
March 20, 2013 - , 2015
Ethical considerations and patient safety concerns for cancelling non-urgent surgeries
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psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
June 24, 2010 - Due to its virulence, patients are clearly impacted, as illustrated by Connie's multiple surgeries and