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psnet.ahrq.gov/node/36583/psn-pdf
January 14, 2011 - The effect of workload on infection risk in critically ill
patients.
January 14, 2011
Hugonnet S, Chevrolet J-C, Pittet D. The effect of workload on infection risk in critically ill patients. Crit
Care Med. 2007;35(1):76-81.
https://psnet.ahrq.gov/issue/effect-workload-infection-risk-critically-ill-patients
Lower…
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psnet.ahrq.gov/node/853060/psn-pdf
August 30, 2023 - Effect of lawsuits on professional well-being and medical
error rates among orthopaedic surgeons.
August 30, 2023
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):893-900. doi:10.5435/jaaos-d-23-00174.…
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psnet.ahrq.gov/node/36837/psn-pdf
December 03, 2018 - Hospitals as cultures of entrapment: a re-analysis of the
Bristol Royal Infirmary.
December 3, 2018
Weick KE, Sutcliffe KM. Hospitals as Cultures of Entrapment: A Re-Analysis of the Bristol Royal Infirmary.
Calif Manage Rev. 2012;45(2):73-84. doi:10.2307/41166166.
https://psnet.ahrq.gov/issue/hospitals-cultures-en…
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psnet.ahrq.gov/node/44730/psn-pdf
December 08, 2015 - Why studying human behavior is a critical component of
patient safety.
December 8, 2015
Su L. Why Studying Human Behavior is a Critical Component of Patient Safety. Curr Probl Pediatr Adolesc
Health Care. 2015;45(12):367-9. doi:10.1016/j.cppeds.2015.10.004.
https://psnet.ahrq.gov/issue/why-studying-human-behavior-…
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psnet.ahrq.gov/node/46048/psn-pdf
July 05, 2017 - Association between elements of electronic health record
systems and the weekend effect in urgent general
surgery.
July 5, 2017
Kothari A, Brownlee SA, Blackwell RH, et al. Association Between Elements of Electronic Health Record
Systems and the Weekend Effect in Urgent General Surgery. JAMA Surg. 2017;152(6):602-…
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psnet.ahrq.gov/node/47688/psn-pdf
March 19, 2019 - Evaluation of an electronic health record structured
discharge summary to provide real time adverse event
reporting in thoracic surgery.
March 19, 2019
Graham AJ, Ocampo W, Southern DA, et al. Evaluation of an electronic health record structured discharge
summary to provide real time adverse event reporting in tho…
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psnet.ahrq.gov/node/35544/psn-pdf
March 29, 2010 - How surgeons disclose medical errors to patients: a
study using standardized patients.
March 29, 2010
Chan DK, Gallagher TH, Reznick R, et al. How surgeons disclose medical errors to patients: a study using
standardized patients. Surgery. 2005;138(5):851-8.
https://psnet.ahrq.gov/issue/how-surgeons-disclose-medi…
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psnet.ahrq.gov/node/45357/psn-pdf
October 09, 2016 - Leading article: how can I optimise my role as a leader
within the surgical team?
October 9, 2016
Green B, Mitchell DA, Stevenson P, et al. Leading article: how can I optimise my role as a leader within the
surgical team? Br J Oral Maxillofac Surg. 2016;54(8):847-850. doi:10.1016/j.bjoms.2016.05.035.
https://psnet…
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psnet.ahrq.gov/node/860015/psn-pdf
September 01, 2024 - Retained Surgical Items: Definition and Epidemiology.
January 4, 2024
Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
Background
Prudent medical practice and federal and state laws r…
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psnet.ahrq.gov/node/49794/psn-pdf
May 01, 2017 - Communication Error in a Closed ICU
May 1, 2017
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/communication-error-closed-icu
The Case
A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney
transplant), co…
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psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
February 24, 2021 - SPOTLIGHT CASE
Is the "Surgical Personality" a Threat to Patient Safety?
Citation Text:
Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citati…
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psnet.ahrq.gov/node/49512/psn-pdf
May 01, 2006 - Right? Left? Neither!
May 1, 2006
Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-left-neither
Case Objectives
Appreciate the role of Reason's Swiss Cheese Model in medical errors
Understand the process of analyzing a single error
Provide suggestions for …
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psnet.ahrq.gov/node/846127/psn-pdf
March 15, 2023 - Sepsis Resulting from Delays in Treatment and
Miscommunication among Specialists
March 15, 2023
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-
spec…
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psnet.ahrq.gov/node/836978/psn-pdf
May 16, 2022 - Check Twice, Transport Once
May 16, 2022
DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/check-twice-transport-once
The Case
Case #1: A 26-year-old woman (Patient A) presented to the Emergency Department (ED) with abdominal
pain and was diagnosed with “s…
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psnet.ahrq.gov/node/840175/psn-pdf
November 16, 2022 - Mechanical Prosthetic Valve Thrombosis with
Thromboembolism.
November 16, 2022
Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. PSNet [internet].
2022.
https://psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
The Case
A 61-year-old woman presented to …
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psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-facha
June 30, 2021 - First, cancel elective surgeries and restrict to emergency surgeries only.
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psnet.ahrq.gov/perspective/covid-19-and-built-environment
June 30, 2021 - First, cancel elective surgeries and restrict to emergency surgeries only.
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psnet.ahrq.gov/node/73549/psn-pdf
July 28, 2021 - Local Anesthesia-Induced Coma During Total Knee
Arthroplasty.
July 28, 2021
Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
The Case
A 61-year-old male patient weighing 57…
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psnet.ahrq.gov/node/867691/psn-pdf
March 05, 2025 - Surgeon perception and attitude towards the moral
imperative of institutionally addressing second-victim
syndrome in surgery.
March 5, 2025
Hsiao L-H, Kopar PK. Surgeon perception and attitude towards the moral imperative of institutionally
addressing second-victim syndrome in surgery. J Am Coll Surg. 2025;240(2):…
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psnet.ahrq.gov/node/46618/psn-pdf
June 25, 2018 - Identifying quality markers of a safe surgical ward: an
interview study of patients, clinical staff, and
administrators.
June 25, 2018
Hassen Y, Singh P, Pucher PH, et al. Identifying quality markers of a safe surgical ward: An interview study
of patients, clinical staff, and administrators. Surgery. 2018;163(6):1…