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psnet.ahrq.gov/issue/clinicians-perspectives-proactive-patient-safety-behaviors-perioperative-environment
May 24, 2023 - Study
Clinicians' perspectives on proactive patient safety behaviors in the perioperative environment.
Citation Text:
Duffy C, Menon N, Horak D, et al. Clinicians' perspectives on proactive patient safety behaviors in the perioperative environment. JAMA Netw Open. 2023;6(4):e237621. doi:…
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psnet.ahrq.gov/issue/association-acute-covid-19-infection-patient-safety-indicator-12-events-multisite-healthcare
January 18, 2023 - Study
The association of acute COVID-19 infection with Patient Safety Indicator-12 events in a multisite healthcare system.
Citation Text:
Bhakta S, Pollock BD, Erben YM, et al. The association of acute COVID‐19 infection with Patient Safety Indicator‐12 events in a multisite healthcare …
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psnet.ahrq.gov/issue/patients-perspectives-quality-and-patient-safety-failures-lessons-learned-inquiry
September 28, 2017 - Study
Patients' perspectives on quality and patient safety failures: lessons learned from an inquiry into transvaginal mesh in Australia.
Citation Text:
Motamedi M, Degeling C, M. Carter S. Patients’ perspectives on quality and patient safety failures: lessons learned from an inquiry int…
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psnet.ahrq.gov/node/49725/psn-pdf
January 01, 2015 - Haste Makes Care Unsafe
January 1, 2015
Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
The Case
An 80-year-old man with a history of coronary artery disease and atrial fibrillation underwent a combined
elective coronary artery bypass graft (CABG…
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psnet.ahrq.gov/periodic-issue/periodic-issue-473
March 25, 2025 - March 5, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
August 10, 2019 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable
Citation Text:
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy C…
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psnet.ahrq.gov/node/39551/psn-pdf
May 26, 2010 - Simulation-based training improves physicians'
performance in patient care in high-stakes clinical setting
of cardiac surgery.
May 26, 2010
Bruppacher HR, Alam SK, LeBlanc VR, et al. Simulation-based training improves physicians' performance
in patient care in high-stakes clinical setting of cardiac surgery. Anest…
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psnet.ahrq.gov/node/39302/psn-pdf
February 17, 2010 - Preoperative briefing in the operating room: shared
cognition, teamwork, and patient safety.
February 17, 2010
Einav Y, Gopher D, Kara I, et al. Preoperative briefing in the operating room: shared cognition, teamwork,
and patient safety. Chest. 2010;137(2):443-9. doi:10.1378/chest.08-1732.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/40726/psn-pdf
July 03, 2014 - Automated identification of postoperative complications
within an electronic medical record using natural
language processing.
July 3, 2014
Murff HJ, FitzHenry F, Matheny ME, et al. Automated identification of postoperative complications within an
electronic medical record using natural language processing. JAMA. …
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psnet.ahrq.gov/node/37908/psn-pdf
June 10, 2010 - Incidence and characteristics of potential and actual
retained foreign object events in surgical patients.
June 10, 2010
Cima RR, Kollengode A, Garnatz J, et al. Incidence and characteristics of potential and actual retained
foreign object events in surgical patients. J Am Coll Surg. 2008;207(1):80-7.
doi:10.1016/…
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psnet.ahrq.gov/node/37327/psn-pdf
March 03, 2011 - Patterns of technical error among surgical malpractice
claims: an analysis of strategies to prevent injury to
surgical patients.
March 3, 2011
Regenbogen SE, Greenberg CC, Studdert DM, et al. Patterns of technical error among surgical malpractice
claims: an analysis of strategies to prevent injury to surgical pati…
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psnet.ahrq.gov/node/43785/psn-pdf
May 01, 2015 - Evaluation of the effectiveness of a surgical checklist in
Medicare patients.
May 1, 2015
Reames BN, Scally CP, Thumma JR, et al. Evaluation of the Effectiveness of a Surgical Checklist in
Medicare Patients. Med Care. 2015;53(1):87-94. doi:10.1097/MLR.0000000000000277.
https://psnet.ahrq.gov/issue/evaluation-effec…
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psnet.ahrq.gov/node/47716/psn-pdf
June 26, 2019 - Magnitude and modifiers of the weekend effect in hospital
admissions: a systematic review and meta-analysis.
June 26, 2019
Chen Y-F, Armoiry X, Higenbottam C, et al. Magnitude and modifiers of the weekend effect in hospital
admissions: a systematic review and meta-analysis. BMJ Open. 2019;9(6):e025764. doi:10.1136/…
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psnet.ahrq.gov/node/37768/psn-pdf
April 27, 2010 - The wisdom and justice of not paying for "preventable
complications."
April 27, 2010
Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable
complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.18.2197.
https://psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-prevent…
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psnet.ahrq.gov/node/44925/psn-pdf
July 27, 2018 - Improving safety for hospitalized patients: much progress
but many challenges remain.
July 27, 2018
Kronick R, Arnold S, Brady J. Improving Safety for Hospitalized Patients: Much Progress but Many
Challenges Remain. JAMA. 2016;316(5):489-90. doi:10.1001/jama.2016.7887.
https://psnet.ahrq.gov/issue/improving-safety…
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psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
January 29, 2021 - Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.
Citation Text:
Bohringer C. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.. PSNet [internet]. Rockville (MD): Agency for He…
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psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - Spotlight
Spotlight
Fatal PCA Opioid-Induced
Respiratory Depression
Source and Credits
• This presentation is based on the May 2020 AHRQ
WebM&M Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: Sarina Fazio, PhD, RN and Rachelle
Firestone, PharmD, BCCCP
o Editors in Chie…
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psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures
Citation Text:
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/node/612828/psn-pdf
February 23, 2022 - Delayed Diagnosis of Kidney Transplant Complications
February 23, 2022
Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
Objectives
Recognition, early evaluation, and management of kidney …
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psnet.ahrq.gov/node/49805/psn-pdf
September 01, 2017 - The Forgotten Radiographic Read
September 1, 2017
Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/forgotten-radiographic-read
The Case
A 60-year-old woman with peripheral artery disease and chronic mesenteric ischemia was admitted for
management of inferior…