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psnet.ahrq.gov/issue/code-debriefing-department-veterans-affairs-va-medical-team-training-program-improves
August 18, 2010 - Study
Code debriefing from the Department of Veterans Affairs (VA) Medical Team Training Program improves the cardiopulmonary resuscitation code process.
Citation Text:
Percarpio KB, Harris FS, Hatfield BA, et al. Code debriefing from the Department of Veterans Affairs (VA) Medical Tea…
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psnet.ahrq.gov/issue/national-costs-medical-liability-system
May 20, 2015 - Study
Classic
National costs of the medical liability system.
Citation Text:
Mello MM, Chandra A, Gawande AA, et al. National costs of the medical liability system. Health Aff (Millwood). 2010;29(9):1569-1577. doi:10.1377/hlthaff.2009.0807.
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F…
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psnet.ahrq.gov/issue/mortality-trends-after-voluntary-checklist-based-surgical-safety-collaborative
September 24, 2017 - Study
Classic
Mortality trends after a voluntary checklist-based surgical safety collaborative.
Citation Text:
Haynes AB, Edmondson L, Lipsitz S, et al. Mortality Trends After a Voluntary Checklist-based Surgical Safety Collaborative. Ann Surg. 2017;266(6):923-9…
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psnet.ahrq.gov/issue/disorganized-care-findings-iterative-depth-analysis-surgical-morbidity-and-mortality
October 19, 2022 - Study
Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality.
Citation Text:
Anderson CI, Nelson CS, Graham CF, et al. Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality. J Surg Res. 201…
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psnet.ahrq.gov/issue/scaling-safety-south-carolina-surgical-safety-checklist-experience
February 07, 2018 - Study
Scaling safety: the South Carolina Surgical Safety Checklist experience.
Citation Text:
Berry WR, Edmondson L, Gibbons LR, et al. Scaling Safety: The South Carolina Surgical Safety Checklist Experience. Health Aff (Millwood). 2018;37(11):1779-1786. doi:10.1377/hlthaff.2018.0717.
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psnet.ahrq.gov/issue/safety-culture-operating-room-variability-among-perioperative-healthcare-workers
November 17, 2021 - Study
Safety culture in the operating room: variability among perioperative healthcare workers.
Citation Text:
Pimentel MPT, Choi S, Fiumara K, et al. Safety culture in the operating room: variability among perioperative healthcare workers. J Patient Saf. 2021;17(6):412-416. doi:10.1097/…
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psnet.ahrq.gov/issue/interventions-employed-improve-intrahospital-handover-systematic-review
January 20, 2015 - Review
Interventions employed to improve intrahospital handover: a systematic review.
Citation Text:
Robertson ER, Morgan L, Bird S, et al. Interventions employed to improve intrahospital handover: a systematic review. BMJ Qual Saf. 2014;23(7):600-7. doi:10.1136/bmjqs-2013-002309.
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psnet.ahrq.gov/issue/qualitative-content-analysis-retained-surgical-items-learning-root-cause-analysis
December 06, 2023 - Study
A qualitative content analysis of retained surgical items: learning from root cause analysis investigations.
Citation Text:
Hibbert PD, Thomas MJW, Deakin A, et al. A qualitative content analysis of retained surgical items: learning from root cause analysis investigations. Int J Qu…
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psnet.ahrq.gov/issue/patient-outcomes-after-introduction-statewide-icu-nurse-staffing-regulations
June 19, 2019 - Study
Patient outcomes after the introduction of statewide ICU nurse staffing regulations.
Citation Text:
Law AC, Stevens JP, Hohmann S, et al. Patient Outcomes After the Introduction of Statewide ICU Nurse Staffing Regulations. Crit Care Med. 2018;46(10):1563-1569. doi:10.1097/CCM.00000…
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psnet.ahrq.gov/issue/comparison-quality-measures-us-hospitals-physician-vs-nonphysician-chief-executive-officers
July 13, 2022 - Study
Comparison of quality measures from US hospitals with physician vs nonphysician chief executive officers.
Citation Text:
See H, Shreve L, Hartzell S, et al. Comparison of quality measures from US hospitals with physician vs nonphysician chief executive officers. JAMA Netw Open. 202…
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psnet.ahrq.gov/issue/cluster-randomized-trial-evaluate-impact-team-training-surgical-outcomes
April 24, 2018 - Study
Cluster randomized trial to evaluate the impact of team training on surgical outcomes.
Citation Text:
Duclos A, Peix JL, Piriou V, et al. Cluster randomized trial to evaluate the impact of team training on surgical outcomes. Br J Surg. 2016;103(13):1804-1814. doi:10.1002/bjs.10295.…
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists
Citation Text:
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/web-mm/check-wristband
August 03, 2009 - Check the Wristband
Citation Text:
Rosenthal M. Check the Wristband. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/846768/psn-pdf
March 29, 2023 - Endotracheal Tube Fallout in a Patient with Severe
Obesity During Eye Surgery.
March 29, 2023
Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
The Ca…
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psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
August 21, 2005 - Mechanical Prosthetic Valve Thrombosis with Thromboembolism.
Citation Text:
Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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…
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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/49693/psn-pdf
October 01, 2013 - In
general, transgender persons who have not undergone gender-affirmative surgeries or used hormonal
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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
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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/too-tight-control
March 20, 2013 - , 2015
Ethical considerations and patient safety concerns for cancelling non-urgent surgeries