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psnet.ahrq.gov/node/39602/psn-pdf
August 09, 2013 - Postoperative handover: problems, pitfalls, and
prevention of error.
August 9, 2013
Nagpal K, Arora S, Abboudi M, et al. Postoperative handover: problems, pitfalls, and prevention of error.
Ann Surg. 2010;252(1):171-6. doi:10.1097/SLA.0b013e3181dc3656.
https://psnet.ahrq.gov/issue/postoperative-handover-problems-p…
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psnet.ahrq.gov/node/41719/psn-pdf
November 27, 2012 - A systematic review of the effectiveness, compliance, and
critical factors for implementation of safety checklists in
surgery.
November 27, 2012
Borchard A, Schwappach DLB, Barbir A, et al. A systematic review of the effectiveness, compliance, and
critical factors for implementation of safety checklists in surgery…
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psnet.ahrq.gov/node/42400/psn-pdf
July 10, 2013 - Development and reliability of the explicit professional
oral communication observation tool to quantify the use
of non-technical skills in healthcare.
July 10, 2013
Kemper PF, van Noord I, de Bruijne M, et al. Development and reliability of the explicit professional oral
communication observation tool to quantify…
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psnet.ahrq.gov/node/39932/psn-pdf
October 20, 2010 - Incorrect surgical counts: a qualitative analysis.
October 20, 2010
Rowlands A, Steeves R. Incorrect surgical counts: a qualitative analysis. AORN J. 2010;92(4):410-9.
doi:10.1016/j.aorn.2010.01.019.
https://psnet.ahrq.gov/issue/incorrect-surgical-counts-qualitative-analysis
Preventing surgical instruments from be…
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psnet.ahrq.gov/node/44334/psn-pdf
November 20, 2015 - Improvement in detection of wrong-patient errors when
radiologists include patient photographs in their
interpretation of portable chest radiographs.
November 20, 2015
Tridandapani S, Olsen K, Bhatti P. Improvement in Detection of Wrong-Patient Errors When Radiologists
Include Patient Photographs in Their Interpre…
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psnet.ahrq.gov/node/72794/psn-pdf
March 03, 2021 - Intraoperative sentinel events in the era of surgical safety
checklists: results of a national survey.
March 3, 2021
Cramer JD, Balakrishnan K, Roy S, et al. Intraoperative sentinel events in the era of surgical safety
checklists: results of a national survey. OTO Open. 2020;4(4):2473974X2097573.
doi:10.1177/24739…
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psnet.ahrq.gov/node/73216/psn-pdf
May 05, 2021 - Incidence and variables associated with inconsistencies
in opioid prescribing at hospital discharge and its
associated adverse drug outcomes.
May 5, 2021
Kurteva S, Habib B, Moraga T, et al. Incidence and variables associated with inconsistencies in opioid
prescribing at hospital discharge and its associated adver…
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psnet.ahrq.gov/node/838068/psn-pdf
September 14, 2022 - Potentially inappropriate medication administration is
associated with adverse postoperative outcomes in older
surgical patients: a retrospective cohort study.
September 14, 2022
Burfeind KG, Zarnegarnia Y, Tekkali P, et al. Potentially inappropriate medication administration is
associated with adverse postoperati…
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psnet.ahrq.gov/node/46087/psn-pdf
September 24, 2017 - Who is responsible for the safe introduction of new
surgical technology? An important legal precedent from
the da Vinci Surgical System Trials.
September 24, 2017
Pradarelli J, Thornton JP, Dimick JB. Who Is Responsible for the Safe Introduction of New Surgical
Technology?: An Important Legal Precedent From the da…
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psnet.ahrq.gov/node/34085/psn-pdf
February 09, 2011 - Discussion of medical errors in morbidity and mortality
conferences.
February 9, 2011
Pierluissi E, Fischer M, Campbell AR, et al. Discussion of medical errors in morbidity and mortality
conferences. JAMA. 2003;290(21):2838-2842.
https://psnet.ahrq.gov/issue/discussion-medical-errors-morbidity-and-mortality-confer…
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psnet.ahrq.gov/node/60250/psn-pdf
April 22, 2020 - Implementation of a comprehensive unit-based safety
program to reduce surgical site infections in cesarean
delivery.
April 22, 2020
Dieplinger B, Egger M, Jezek C, et al. Implementation of a comprehensive unit-based safety program to
reduce surgical site infections in cesarean delivery. Am J Infect Control. 2020;4…
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psnet.ahrq.gov/node/36604/psn-pdf
June 04, 2024 - Adverse Health Events in Minnesota: Annual Reports.
June 4, 2024
St Paul, MN: Minnesota Department of Health.
https://psnet.ahrq.gov/issue/adverse-health-events-minnesota-15th-annual-public-report
The National Quality Forum has defined 29 never events—patient safety problems that should never occur,
such as wrong-…
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psnet.ahrq.gov/node/47436/psn-pdf
December 21, 2018 - Views of nurses and other health and social care workers
on the use of assistive humanoid and animal-like robots
in health and social care: a scoping review.
December 21, 2018
Papadopoulos I, Koulouglioti C, Ali S. Views of nurses and other health and social care workers on the use
of assistive humanoid and animal…
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psnet.ahrq.gov/node/45578/psn-pdf
January 23, 2017 - S-TEAMS: a truly multiprofessional course focusing on
nontechnical skills to improve patient safety in the
operating theater.
January 23, 2017
Stewart-Parker E, Galloway R, Vig S. S-TEAMS: A Truly Multiprofessional Course Focusing on
Nontechnical Skills to Improve Patient Safety in the Operating Theater. J Surg Ed…
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psnet.ahrq.gov/issue/preventing-surgical-site-infections-implementing-strategies-throughout-perioperative
January 15, 2025 - Commentary
Preventing surgical site infections: implementing strategies throughout the perioperative continuum.
Citation Text:
Rosa R, Sposato K, Abbo LM. Preventing surgical site infections: implementing strategies throughout the perioperative continuum. AORN J. 2023;117(5):300-311. doi…
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psnet.ahrq.gov/issue/surgeon-reported-conflict-intensivists-about-postoperative-goals-care
September 26, 2012 - Study
Surgeon-reported conflict with intensivists about postoperative goals of care.
Citation Text:
Olson TJP, Brasel KJ, Redmann AJ, et al. Surgeon-reported conflict with intensivists about postoperative goals of care. JAMA Surg. 2013;148(1):29-35. doi:10.1001/jamasurgery.2013.403.
Co…
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psnet.ahrq.gov/issue/pursuing-professional-accountability-evidence-based-approach-addressing-residents-behavioral
January 18, 2012 - Commentary
Pursuing professional accountability: an evidence-based approach to addressing residents with behavioral problems.
Citation Text:
Sanfey H, DaRosa DA, Hickson GB, et al. Pursuing professional accountability: an evidence-based approach to addressing residents with behavioral pr…
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psnet.ahrq.gov/issue/use-surgical-safety-checklist-improve-team-communication
August 08, 2018 - Commentary
Use of a surgical safety checklist to improve team communication.
Citation Text:
Cabral RA, Eggenberger T, Keller K, et al. Use of a surgical safety checklist to improve team communication. AORN J. 2016;104(3):206-216. doi:10.1016/j.aorn.2016.06.019.
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psnet.ahrq.gov/issue/natural-history-retained-surgical-items-supports-need-team-training-early-recognition-and
January 18, 2013 - Study
Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval.
Citation Text:
Stawicki P, Cook CH, Anderson HL, et al. Natural history of retained surgical items supports the need for team training, early recognition, and pr…
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psnet.ahrq.gov/issue/top-10-list-safe-and-effective-sign-out
April 12, 2019 - Commentary
The top 10 list for a safe and effective sign-out.
Citation Text:
Kemp CD, Bath JM, Berger J, et al. The top 10 list for a safe and effective sign-out. Arch Surg. 2008;143(10):1008-10. doi:10.1001/archsurg.143.10.1008.
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