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psnet.ahrq.gov/issue/management-adverse-surgical-events-structured-education-module-residents
August 26, 2011 - Study
Management of adverse surgical events: a structured education module for residents.
Citation Text:
Brewster LP, Risucci DA, Joehl RJ, et al. Management of adverse surgical events: a structured education module for residents. Am J Surg. 2005;190(5):687-90.
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psnet.ahrq.gov/issue/creating-safer-operating-room-groups-team-dynamics-and-crew-resource-management-principles
June 11, 2008 - Review
Emerging Classic
Creating a safer operating room: groups, team dynamics and crew resource management principles.
Citation Text:
Wakeman D, Langham MR. Creating a safer operating room: Groups, team dynamics and crew resource management principles. Semin Pe…
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psnet.ahrq.gov/issue/monitoring-medication-errors-outpatient-settings
December 31, 2014 - Review
Monitoring for medication errors in outpatient settings.
Citation Text:
Balkrishnan R, Foss CE, Pawaskar M, et al. Monitoring for medication errors in outpatient settings. J Dermatolog Treat. 2009;20(4):229-32. doi:10.1080/09546630802607487.
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psnet.ahrq.gov/issue/recurring-problem-retained-swabs-and-instruments
June 19, 2019 - Review
The recurring problem of retained swabs and instruments.
Citation Text:
Mahran MA, Toeima E, Morris EP. The recurring problem of retained swabs and instruments. Best Pract Res Clin Obstet Gynaecol. 2013;27(4):489-95. doi:10.1016/j.bpobgyn.2013.03.001.
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psnet.ahrq.gov/issue/how-surgical-trainees-handle-catastrophic-errors-qualitative-study
March 19, 2019 - Study
How surgical trainees handle catastrophic errors: a qualitative study.
Citation Text:
Balogun JA, Bramall AN, Bernstein M. How Surgical Trainees Handle Catastrophic Errors: A Qualitative Study. J Surg Educ. 2015;72(6):1179-84. doi:10.1016/j.jsurg.2015.05.003.
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psnet.ahrq.gov/issue/clinical-care-checklists-salvations-or-frustrations
September 01, 2018 - Commentary
Clinical care checklists: salvations or frustrations?
Citation Text:
Jones JW, McCullough LB. Clinical care checklists: salvations or frustrations? J Vasc Surg. 2011;53(5):1429-30. doi:10.1016/j.jvs.2011.02.024.
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psnet.ahrq.gov/issue/case-improving-measurement-intraoperative-iatrogenic-injuries
February 14, 2017 - Commentary
A case for improving measurement of intraoperative iatrogenic injuries.
Citation Text:
Paruch JL, Ko CY, Bilimoria KY. A case for improving measurement of intraoperative iatrogenic injuries. JAMA Surg. 2014;149(9):887-8. doi:10.1001/jamasurg.2013.5237.
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psnet.ahrq.gov/issue/chasing-6-sigma-drawing-lessons-cockpit-culture
April 22, 2015 - Commentary
Chasing the 6-sigma: drawing lessons from the cockpit culture.
Citation Text:
Hickey EJ, Halvorsen F, Laussen PC, et al. Chasing the 6-sigma: Drawing lessons from the cockpit culture. J Thorac Cardiovasc Surg. 2017;155(2). doi:10.1016/j.jtcvs.2017.09.097.
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psnet.ahrq.gov/issue/enhancing-pediatric-perioperative-patient-safety
January 28, 2015 - Commentary
Enhancing pediatric perioperative patient safety.
Citation Text:
Johnson Q, McVey J. Enhancing Pediatric Perioperative Patient Safety. AORN J. 2017;106(5):434-442. doi:10.1016/j.aorn.2017.09.007.
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psnet.ahrq.gov/issue/formalizing-hidden-curriculum-performance-enhancing-errors
February 17, 2021 - Review
Formalizing the hidden curriculum of performance enhancing errors.
Citation Text:
Kerray FM, Yule SJ, Tambyraja AL. Formalizing the hidden curriculum of performance enhancing errors. J Surg Educ. 2023;80(5):619-623. doi:10.1016/j.jsurg.2023.01.009.
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psnet.ahrq.gov/issue/meta-analysis-surgical-safety-checklist-effects-teamwork-communication-morbidity-mortality
April 12, 2017 - Review
Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, and safety.
Citation Text:
Lyons VE, Popejoy LL. Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, and safety. West J Nurs Res.…
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psnet.ahrq.gov/issue/teamwork-and-error-operating-room-analysis-skills-and-roles
April 15, 2009 - Study
Teamwork and error in the operating room: analysis of skills and roles.
Citation Text:
Catchpole K, Mishra A, Handa A, et al. Teamwork and error in the operating room: analysis of skills and roles. Ann Surg. 2008;247(4):699-706. doi:10.1097/SLA.0b013e3181642ec8.
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psnet.ahrq.gov/issue/do-micropauses-prevent-surgeons-fatigue-and-loss-accuracy-associated-prolonged-surgery
November 29, 2023 - Study
Do micropauses prevent surgeon's fatigue and loss of accuracy associated with prolonged surgery? An experimental prospective study.
Citation Text:
Dorion D, Darveau S. Do micropauses prevent surgeon's fatigue and loss of accuracy associated with prolonged surgery? An experimental…
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psnet.ahrq.gov/issue/simulation-based-clinical-rehearsals-method-improving-patient-safety
September 28, 2022 - Commentary
Simulation-based clinical rehearsals as a method for improving patient safety.
Citation Text:
Arnold J, Cashin M, Olutoye OO. Simulation-Based Clinical Rehearsals as a Method for Improving Patient Safety. JAMA Surg. 2018;153(12):1143-1144. doi:10.1001/jamasurg.2018.3526.
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psnet.ahrq.gov/issue/wrong-site-craniotomy-analysis-35-cases-and-systems-prevention
November 16, 2022 - Study
Wrong-site craniotomy: analysis of 35 cases and systems for prevention.
Citation Text:
Cohen FL, Mendelsohn D, Bernstein M. Wrong-site craniotomy: analysis of 35 cases and systems for prevention. J Neurosurg. 2010;113(3):461-73. doi:10.3171/2009.10.JNS091282.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_overview_impmodel_facnotes.docx
December 01, 2017 - Estimates suggest that 25 percent of patients undergoing inpatient surgeries develop complications, and
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www.ahrq.gov/sites/default/files/wysiwyg/SOPS-International-Countries-September-2022-508-rev.pdf
January 01, 2022 - SOPS International Use by Country
International Use: Countries Where SOPS® Has Been Administered
As of September 2022, there are 107 known countries where the AHRQ Surveys on Patient Safety Culture™ (SOPS®)
Surveys and Supplemental Item Sets have been administered.
Counties
Hospital
1.0
Hospital
2.0
Medic…
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effectivehealthcare.ahrq.gov/sites/default/files/braddock.pdf
January 01, 2011 - Braddock
Slide 1: Supporting
Shared Decision Making
When Clinical Evidence is
Low
Clarence H. Braddock III, MD, MPH, FACP
Professor of Medicine and Associate Dean
Stanford
School of Medicine
Slide 2: Overview
• Ethical foundations of SDM
• Conceptual model for SDM, patient …
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - first seven days after surgery
• In an observational study of nearly 46,000 consecutive orthopedic
surgeries
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psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
May 08, 2019 - Miscommunication in the OR Leads to Anticoagulation Mishap
Citation Text:
Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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