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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/surgical-safety-checklist-reduce-morbidity-and-mortality-global-population
February 09, 2011 - Study
Classic
A surgical safety checklist to reduce morbidity and mortality in a global population.
Citation Text:
Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;3…
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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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digital.ahrq.gov/principal-investigator/kent-k-craig
January 01, 2023 - Kent, K Craig
Feasibility of an image-based mobile health protocol for postoperative wound monitoring.
Citation
Gunter RL, Fernandes-Taylor S, Rahman S, et al. Feasibility of an image-based mobile health protocol for postoperative wound monitoring. J Am Coll Surg 2018 Mar;226(…
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psnet.ahrq.gov/issue/covid-19-hospital-outbreaks-protecting-healthcare-workers-protect-frail-patients-italian
March 18, 2020 - Study
COVID-19 hospital outbreaks: protecting healthcare workers to protect frail patients. An Italian observational cohort study.
Citation Text:
Vimercati L, De Maria L, Quarato M, et al. COVID-19 hospital outbreaks: Protecting healthcare workers to protect frail patients. An Italian ob…
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digital.ahrq.gov/technology/imaging-system
January 01, 2023 - Imaging System
Impact of an electronic alert notification system embedded in radiologists' workflow on closed-loop communication of critical results: a time series analysis.
Citation
Lacson R, O'Connor SD, Sahni VA, et al. Impact of an electronic alert notification system embe…
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psnet.ahrq.gov/issue/potential-consequences-patient-complications-surgeon-well-being-systematic-review
May 23, 2018 - Review
Potential consequences of patient complications for surgeon well-being: a systematic review.
Citation Text:
Srinivasa S, Gurney J, Koea J. Potential Consequences of Patient Complications for Surgeon Well-being: A Systematic Review. JAMA Surg. 2019;154(5):451-457. doi:10.1001/jamas…
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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/issue/outcomes-daytime-procedures-performed-attending-surgeons-after-night-work
December 18, 2014 - Study
Classic
Outcomes of daytime procedures performed by attending surgeons after night work.
Citation Text:
Govindarajan A, Urbach DR, Kumar M, et al. Outcomes of Daytime Procedures Performed by Attending Surgeons after Night Work. N Engl J Med. 2015;373(9):84…
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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/understanding-enablers-and-barriers-implementing-patient-led-escalation-system-qualitative
January 18, 2023 - Study
Understanding the enablers and barriers to implementing a patient-led escalation system: a qualitative study.
Citation Text:
Sutton E, Ibrahim M, Plath W, et al. Understanding the enablers and barriers to implementing a patient-led escalation system: a qualitative study. BMJ Qual S…
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psnet.ahrq.gov/issue/international-recommendations-national-patient-safety-incident-reporting-systems-expert
February 14, 2018 - Study
International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process.
Citation Text:
Howell A-M, Burns EM, Hull L, et al. International recommendations for national patient safety incident reporting systems: an expert Del…
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psnet.ahrq.gov/issue/medical-team-training-and-coaching-veterans-health-administration-assessment-and-impact-first
December 21, 2014 - Study
Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme.
Citation Text:
Neily J, Mills PD, Lee P, et al. Medical team training and coaching in the Veterans Health Administration; assessment and im…
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psnet.ahrq.gov/issue/influence-external-assessment-quality-and-safety-surgery-qualitative-study-surgeons
June 28, 2023 - Study
Influence of external assessment on quality and safety in surgery: a qualitative study of surgeons' perspectives.
Citation Text:
Øyri SF, Wiig S, Tjomsland O. Influence of external assessment on quality and safety in surgery: a qualitative study of surgeons’ perspectives. BMJ Open …
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psnet.ahrq.gov/node/49423/psn-pdf
November 01, 2003 - The Missing Suction Tip
November 1, 2003
Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/missing-suction-tip
Case Objectives
Identify the risk factors for retained foreign bodies.
Understand methods used to prevent and identify retained foreign bodies.
Apprecia…
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psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
April 01, 2003 - The Wild West: Patient Safety in Office-Based Anesthesia
Rainu Kaushal, MD MPH; Sekhar Upadhyayula, MD; David M. Gaba, MD; Lucian L. Leape, MD | May 1, 2006
View more articles from the same authors.
Citation Text:
Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4c_pdi03-foreignbody-bestpractices.pdf
November 01, 2012 - Selected Best Practices and Suggestions for Improvement
Pediatric Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4c
Selected Best Practices and Suggestions for Improvement
PDI 03: Retained Surgical Item or Unretrieved Device Fragment Count
Why focus on reta…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4q_combo_pdi03-foreignbody-bestpractices.pdf
November 01, 2012 - Selected Best Practices and Suggestions for Improvement
Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4q
Selected Best Practices and Suggestions for Improvement
PDI 03: Retained Surgical Item or Unretrieved Device Fragment Count
Why focus on retained forei…
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psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
January 01, 2024 - Spotlight
Spotlight
Missed Connection: A Case of Inadequate ECG
Oversight in Cardiac Surgery
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Christian Bohringer, MBBS, …
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hcup-us.ahrq.gov/reports/methods/methods.jsp
February 01, 2025 - HCUP-US Methods Series
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