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psnet.ahrq.gov/issue/how-does-patient-safety-culture-operating-room-and-post-anesthesia-care-unit-compare-rest October 14, 2009 - Study 
 
 
 
 
 
 
 
 
 
 How does patient safety culture in the operating room and post-anesthesia care unit compare to the rest of the hospital?   
 
 
 
 
 Citation Text: 
 Kaafarani HMA, Itani KMF, Rosen AK, et al. How does patient safety culture in the operating room and post-anesthesia care unit compare to the re…  
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psnet.ahrq.gov/issue/reducing-surgical-specimen-errors-through-multidisciplinary-quality-improvement July 28, 2021 - Study 
 
 
 
 
 
 
 
 
 
 Reducing surgical specimen errors through multidisciplinary quality improvement. 
 
 
 
 
 Citation Text: 
 Holstine JB, Samora JB. Reducing surgical specimen errors through multidisciplinary quality improvement. Jt Comm J Qual Patient Saf. 2021;47(9):563-571. doi:10.1016/j.jcjq.2021.04.003. 
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psnet.ahrq.gov/issue/perioperative-patient-safety-recommendations-systematic-review-clinical-practice-guidelines January 08, 2025 - Study 
 
 
 
 
 
 
 
 
 
 Perioperative patient safety recommendations: systematic review of clinical practice guidelines. 
 
 
 
 
 Citation Text: 
 Martínez-Nicolas I, Arnal-Velasco D, Romero-García E, et al. Perioperative patient safety recommendations: systematic review of clinical practice guidelines. BJS Open. 20…  
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psnet.ahrq.gov/issue/eleven-basic-procedurespractices-dental-patient-safety March 27, 2013 - Commentary 
 
 
 
 
 
 
 
 
 
 Eleven basic procedures/practices for dental patient safety. 
 
 
 
 
 Citation Text: 
 Perea-Pérez B, Labajo-González E, Acosta-Gío AE, et al. Eleven basic procedures/practices for dental patient safety. J Patient Saf. 2020;16(1). doi:10.1097/pts.0000000000000234. 
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 For…  
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psnet.ahrq.gov/issue/anesthetic-mishaps-breaking-chain-accident-evolution April 08, 2011 - Commentary 
 
 
 
 
 
 
 
 
 
            Classic
           
 
 Anesthetic mishaps: breaking the chain of accident evolution.  
 
 
 
 
 Citation Text: 
 Gaba DM, Maxwell M, DeAnda A. Anesthetic mishaps: breaking the chain of accident evolution. Anesthesiology. 1987;66(5):670-6. 
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 Format: 
 
 
 
 Goo…  
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psnet.ahrq.gov/issue/how-perform-root-cause-analysis-workup-and-future-prevention-medical-errors-review August 03, 2017 - Review 
 
 
 
 
 
 
 
 
 
 How to perform a root cause analysis for workup and future prevention of medical errors: a review. 
 
 
 
 
 Citation Text: 
 Charles R, Hood B, DeRosier JM, et al. How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient Saf Surg. 2016;10:20.…  
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psnet.ahrq.gov/issue/implementation-surgical-safety-checklist-and-postoperative-outcomes-prospective-randomized October 10, 2018 - Study 
 
 
 
 
 
 
 
 
 
 Implementation of a surgical safety checklist and postoperative outcomes: a prospective randomized controlled study. 
 
 
 
 
 Citation Text: 
 Chaudhary N, Varma V, Kapoor S, et al. Implementation of a surgical safety checklist and postoperative outcomes: a prospective randomized controlled s…  
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psnet.ahrq.gov/issue/qualitative-study-comparing-experiences-surgical-safety-checklist-hospitals-high-income-and June 16, 2021 - Study 
 
 
 
 
 
 
 
 
 
 A qualitative study comparing experiences of the surgical safety checklist in hospitals in high-income and low-income countries.  
 
 
 
 
 Citation Text: 
 Aveling E-L, McCulloch P, Dixon-Woods M. A qualitative study comparing experiences of the surgical safety checklist in hospitals in high-…  
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psnet.ahrq.gov/issue/guidance-patient-safety-ophthalmology-royal-college-ophthalmologists November 12, 2014 - Review 
 
 
 
 
 
 
 
 
 
 Guidance on patient safety in ophthalmology from the Royal College of Ophthalmologists.   
 
 
 
 
 Citation Text: 
 Kelly SP, Ophthalmologists RC of. Guidance on patient safety in ophthalmology from the Royal College of Ophthalmologists. Eye (Lond). 2009;23(12):2143-51. doi:10.1038/eye.2009.…  
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psnet.ahrq.gov/issue/applying-modern-error-theory-problem-missed-injuries-trauma June 15, 2011 - Study 
 
 
 
 
 
 
 
 
 
 Applying modern error theory to the problem of missed injuries in trauma.   
 
 
 
 
 Citation Text: 
 Clarke DL, Gouveia J, Thomson SR, et al. Applying modern error theory to the problem of missed injuries in trauma. World J Surg. 2008;32(6):1176-82. doi:10.1007/s00268-008-9543-7. 
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psnet.ahrq.gov/issue/evaluating-effect-distractions-operating-room-clinical-decision-making-and-patient-safety November 16, 2022 - Study 
 
 
 
 
 
 
 
 
 
 Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety. 
 
 
 
 
 Citation Text: 
 Murji A, Luketic L, Sobel ML, et al. Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety. Surg Endosc. 2…  
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psnet.ahrq.gov/issue/error-omission-simple-checklist-approach-improving-operating-room-safety August 03, 2022 - Commentary 
 
 
 
 
 
 
 
 
 
 The error of omission: a simple checklist approach for improving operating room safety.   
 
 
 
 
 Citation Text: 
 Rosenfield LK, Chang DS. The error of omission: a simple checklist approach for improving operating room safety. Plast Reconstr Surg. 2009;123(1):399-402. doi:10.1097/PRS.0…  
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psnet.ahrq.gov/issue/crowd-sourced-hospital-ratings-are-correlated-patient-satisfaction-not-surgical-safety November 18, 2020 - Study 
 
 
 
 
 
 
 
 
 
 Crowd-sourced hospital ratings are correlated with patient satisfaction but not surgical safety. 
 
 
 
 
 Citation Text: 
 Synan LT, Eid MA, Lamb CR, et al. Crowd-sourced hospital ratings are correlated with patient satisfaction but not surgical safety. Surgery. 2021;170(3):764-768. doi:10.10…  
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psnet.ahrq.gov/issue/prevalence-burnout-among-surgical-residents-and-surgeons-switzerland December 21, 2014 - Study 
 
 
 
 
 
 
 
 
 
 Prevalence of burnout among surgical residents and surgeons in Switzerland.   
 
 
 
 
 Citation Text: 
 Businger A, Stefenelli U, Guller U. Prevalence of burnout among surgical residents and surgeons in Switzerland. Arch Surg. 2010;145(10):1013-6. doi:10.1001/archsurg.2010.188. 
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Quinn.pdf January 01, 2004 - Can an Academic Health Care System Overcome Barriers to Clinical Guideline Implementation?
291 
Can an Academic Health Care  
System Overcome Barriers to  
Clinical Guideline Implementation? 
Debra Quinn, Mary Cooper, Lynn Chevalier,  
Jerry Balentine, Lawrence Kadish, Steven Walerstein,  
Fredric Weinbaum, Mark Ca…  
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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong March 03, 2021 - SPOTLIGHT CASE
         
 Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. 
 
 
 
 
 Citation Text: 
 Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.. PSNet [internet]. Rockville (MD): Agency fo…  
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www.ahrq.gov/talkingquality/translate/labels/explain-score.html March 01, 2016 - Explain Whether a High or Low Health Care Quality Score Is Better 
 
 
 
 Ideally, all the measures in a given report would be structured so that people were consistently looking for a high score or a low score as an indicator of good performance. Switching directions can be confusing and create a cognitive burden on u…  
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-d.html April 01, 2017 - Appendix D.  Ambulatory Surgery Center Checklist Template - Implementation Guide 
 
 
 
 Ambulatory Surgery Checklist - Preop 
 
 
 
 Before Patient Enters Room 
 
 
 Nurse, Anesthesia Professional, and Patient Review: 
			|___| Patient identification (name and date of birth) 
			|___| Surgical site 
			|___| Surgical …  
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psnet.ahrq.gov/issue/reports-hospital-and-asc-performance October 02, 2024 - Book/Report 
 
 
 
 
 
 
 
 
 
 Reports on Hospital and ASC Performance. 
 
 
 
 
 Citation Text: 
 Reports On Hospital And Asc Performance. Washington DC: The Leapfrog Group; September 2024. 
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 Format: 
 
 
 
 Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS 
 
 
 
 
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psnet.ahrq.gov/node/49427/psn-pdf January 01, 2004 - Inadvertent Castration
January 1, 2004
Calland FJ. Inadvertent Castration. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/inadvertent-castration
The Case
An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently
increased in size. The patient described persisten…