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psnet.ahrq.gov/issue/preventing-wrong-site-procedure-and-patient-events-using-common-cause-analysis
October 03, 2017 - Study
Preventing wrong site, procedure, and patient events using a common cause analysis.
Citation Text:
Mallett R, Conroy M, Saslaw LZ, et al. Preventing wrong site, procedure, and patient events using a common cause analysis. Am J Med Qual. 2012;27(1):21-9. doi:10.1177/10628606114120…
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psnet.ahrq.gov/issue/evaluation-reasons-why-surgical-residents-exceeded-2011-duty-hour-requirements-when-offered
September 02, 2020 - Study
Evaluation of reasons why surgical residents exceeded 2011 duty hour requirements when offered flexibility.
Citation Text:
Blay E, Engelhardt KE, Hewitt B, et al. Evaluation of Reasons Why Surgical Residents Exceeded 2011 Duty Hour Requirements When Offered Flexibility: A FIRST Tri…
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psnet.ahrq.gov/issue/impact-who-surgical-safety-checklist-relative-its-design-and-intended-use-systematic-review
March 17, 2021 - Review
Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review and meta-meta-analysis.
Citation Text:
Sotto KT, Burian BK, Brindle ME. Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review…
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psnet.ahrq.gov/issue/systems-approach-analyzing-and-preventing-hospital-adverse-events
March 30, 2022 - Study
Emerging Classic
A systems approach to analyzing and preventing hospital adverse events.
Citation Text:
Leveson N, Samost A, Dekker SWA, et al. A systems approach to analyzing and preventing hospital adverse events. J Patient Saf. 2020;16(2):162-167. doi:1…
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psnet.ahrq.gov/issue/acgme-2011-duty-hours-restrictions-and-their-effects-surgical-residency-training-and-patients
August 26, 2020 - Review
ACGME 2011 duty hours restrictions and their effects on surgical residency training and patients outcomes: a systematic review.
Citation Text:
Awan M, Zagales I, McKenney M, et al. ACGME 2011 duty hours restrictions and their effects on surgical residency training and patients out…
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psnet.ahrq.gov/issue/complications-daytime-elective-laparoscopic-cholecystectomies-performed-surgeons-who-operated
April 12, 2019 - Study
Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before.
Citation Text:
Vinden C, Nash DM, Rangrej J, et al. Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night be…
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psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced
Respiratory Depression
May 27, 2020
Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-
…
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - Obesity, adhesive disease from prior surgeries (especially of the foregut), and atypical location of
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psnet.ahrq.gov/issue/adverse-events-operating-room-definitions-prevalence-and-characteristics-systematic-review
July 25, 2018 - Review
Adverse events in the operating room: definitions, prevalence, and characteristics. A systematic review.
Citation Text:
Jung JJ, Elfassy J, Jüni P, et al. Adverse Events in the Operating Room: Definitions, Prevalence, and Characteristics. A Systematic Review. World J Surg. 2019;4…
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psnet.ahrq.gov/issue/interprofessional-staff-perspectives-adoption-or-black-box-technology-and-simulations-improve
May 21, 2009 - Study
Interprofessional staff perspectives on the adoption of OR black box technology and simulations to improve patient safety: a multi-methods survey.
Citation Text:
Campbell K, Gardner A, Scott DJ, et al. Interprofessional staff perspectives on the adoption of or black box technology …
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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/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
January 29, 2021 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon
Citation Text:
Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/issue/taking-bullying-out-health-care-patient-safety-imperative
June 19, 2024 - Commentary
Taking bullying out of health care: a patient safety imperative.
Citation Text:
Ross J. Taking Bullying Out of Health Care: A Patient Safety Imperative. J Perianesth Nurs. 2017;32(6):653-655. doi:10.1016/j.jopan.2017.08.006.
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Format:
DOI Google Schol…
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psnet.ahrq.gov/issue/patient-safety-supporting-culture-continuous-quality-improvement-hospitals-and-other-health
August 09, 2023 - Congressional Testimony
Patient Safety: Supporting a Culture of Continuous Quality Improvement in Hospitals and Other Health Care Organizations.
Citation Text:
Patient Safety: Supporting a Culture of Continuous Quality Improvement in Hospitals and Other Health Care Organizations. Cla…
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psnet.ahrq.gov/issue/relationship-between-patient-safety-and-hospital-surgical-volume
May 04, 2012 - Study
Relationship between patient safety and hospital surgical volume.
Citation Text:
Hernandez-Boussard T, Downey JR, McDonald KM, et al. Relationship between Patient Safety and Hospital Surgical Volume. Health Serv Res. 2011;47(2). doi:10.1111/j.1475-6773.2011.01310.x.
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psnet.ahrq.gov/issue/wrong-side-thoracentesis-lessons-learned-root-cause-analysis
July 16, 2015 - Study
Wrong-side thoracentesis: lessons learned from root cause analysis.
Citation Text:
Miller K, Mims M, Paull DE, et al. Wrong-side thoracentesis: lessons learned from root cause analysis. JAMA Surg. 2014;149(8):774-9. doi:10.1001/jamasurg.2014.146.
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psnet.ahrq.gov/issue/new-professionalism-surgical-residents-duty-hours-restrictions-and-shift-transitions
October 19, 2022 - Study
A new professionalism? Surgical residents, duty hours restrictions, and shift transitions.
Citation Text:
Coverdill JE, Carbonell AM, Fryer J, et al. A new professionalism? Surgical residents, duty hours restrictions, and shift transitions. Acad Med. 2010;85(10 Suppl):S72-5. doi:1…
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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/issue/where-are-my-instruments-hazards-delivery-surgical-instruments
September 25, 2008 - Study
Where are my instruments? Hazards in delivery of surgical instruments.
Citation Text:
Guédon ACP, Wauben LSGL, van der Eijk AC, et al. Where are my instruments? Hazards in delivery of surgical instruments. Surg Endosc. 2016;30(7):2728-35. doi:10.1007/s00464-015-4537-7.
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psnet.ahrq.gov/issue/measuring-variation-use-who-surgical-safety-checklist-operating-room-multicenter-prospective
January 19, 2016 - Study
Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study.
Citation Text:
Russ S, Rout S, Caris J, et al. Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicente…