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psnet.ahrq.gov/node/41438/psn-pdf
January 03, 2017 - Implementing SBAR across a large multihospital health
system.
January 3, 2017
Compton J, Copeland K, Flanders S, et al. Implementing SBAR across a large multihospital health system.
Jt Comm J Qual Patient Saf. 2012;38(6):261-8.
https://psnet.ahrq.gov/issue/implementing-sbar-across-large-multihospital-health-system…
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psnet.ahrq.gov/node/41110/psn-pdf
January 18, 2013 - Applying aviation factors to oral and maxillofacial
surgery—the human element.
January 18, 2013
Seager L, Smith DW, Patel A, et al. Applying aviation factors to oral and maxillofacial surgery--the human
element. Br J Oral Maxillofac Surg. 2013;51(1):8-13. doi:10.1016/j.bjoms.2011.11.024.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/40440/psn-pdf
July 02, 2014 - Residents' reflections on quality improvement: temporal
stability and associations with preventability of adverse
patient events.
July 2, 2014
Wittich CM, Reed DA, Drefahl MM, et al. Residents' reflections on quality improvement: temporal stability
and associations with preventability of adverse patient events. Ac…
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psnet.ahrq.gov/node/43181/psn-pdf
May 14, 2014 - Overextended: fighting the fatigue of long shifts.
May 14, 2014
Douglass JA. Overextended: Fighting the fatigue of long shifts. Nursing (Brux). 2014;44(3):67-8.
doi:10.1097/01.NURSE.0000441895.42899.0c.
https://psnet.ahrq.gov/issue/overextended-fighting-fatigue-long-shifts
Many studies have demonstrated the link b…
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psnet.ahrq.gov/node/72537/psn-pdf
December 02, 2020 - Automation failures and patient safety.
December 2, 2020
Ruskin KJ, Ruskin AC, O’Connor M. Automation failures and patient safety. Curr Opin Anaesthesiol.
2020;33(6):788-792. doi:10.1097/aco.0000000000000935.
https://psnet.ahrq.gov/issue/automation-failures-and-patient-safety
Task automation in medicine is a core …
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psnet.ahrq.gov/node/44144/psn-pdf
May 27, 2015 - Maintaining safety in the dialysis facility.
May 27, 2015
Kliger AS. Maintaining safety in the dialysis facility. Clin J Am Soc Nephrol. 2015;10(4):688-95.
doi:10.2215/CJN.08960914.
https://psnet.ahrq.gov/issue/maintaining-safety-dialysis-facility
Failure to consider human factors and poor communication can contri…
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psnet.ahrq.gov/node/35282/psn-pdf
May 27, 2011 - Comprehensive analysis of a medication dosing error
related to CPOE.
May 27, 2011
Horsky J, Kuperman GJ, Patel VL. Comprehensive Analysis of a Medication Dosing Error Related to
CPOE: Table 1. J Am Med Info Assoc. 2005;12(4). doi:10.1197/jamia.m1740.
https://psnet.ahrq.gov/issue/comprehensive-analysis-medication-d…
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psnet.ahrq.gov/node/42901/psn-pdf
January 29, 2014 - Do safety checklists improve teamwork and
communication in the operating room? A systematic
review.
January 29, 2014
Russ S, Rout S, Sevdalis N, et al. Do safety checklists improve teamwork and communication in the
operating room? A systematic review. Ann Surg. 2013;258(6):856-71.
doi:10.1097/SLA.0000000000000206…
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psnet.ahrq.gov/node/50781/psn-pdf
January 08, 2020 - Harnessing the power of medical malpractice data to
improve patient care.
January 8, 2020
Siegal D, Swift J, Forget J, et al. Harnessing the power of medical malpractice data to improve patient care.
J Healthc Risk Manag. 2020;39(3):28-36. doi:10.1002/jhrm.21393.
https://psnet.ahrq.gov/issue/harnessing-power-medic…
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psnet.ahrq.gov/node/845080/psn-pdf
February 22, 2023 - A high-reliability organization mindset.
February 22, 2023
Merchant NB, O’Neal J, Dealino-Perez C, et al. A high-reliability organization mindset. Am J Med Qual.
2022;37(6):504-510. doi:10.1097/jmq.0000000000000086.
https://psnet.ahrq.gov/issue/high-reliability-organization-mindset
The goal for health care organiz…
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psnet.ahrq.gov/node/43529/psn-pdf
October 01, 2014 - National pediatric anesthesia safety quality improvement
program in the United States.
October 1, 2014
Kurth D, Tyler D, Heitmiller ES, et al. National pediatric anesthesia safety quality improvement program in
the United States. Anesth Analg. 2014;119(1):112-21. doi:10.1213/ANE.0000000000000040.
https://psnet.ahr…
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psnet.ahrq.gov/node/42506/psn-pdf
August 28, 2013 - Foundations for teaching surgeons to address the
contributions of systems to operating room team conflict.
August 28, 2013
Rogers DA, Lingard LA, Boehler ML, et al. Foundations for teaching surgeons to address the contributions
of systems to operating room team conflict. Am J Surg. 2013;206(3):428-32.
doi:10.1016/…
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psnet.ahrq.gov/node/46363/psn-pdf
December 13, 2017 - Exploring how nursing schools handle student errors and
near misses.
December 13, 2017
Disch J, Barnsteiner J, Connor S, et al. CE: Original Research: Exploring How Nursing Schools Handle
Student Errors and Near Misses. Am J Nurs. 2017;117(10):24-31.
doi:10.1097/01.NAJ.0000525849.35536.74.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/45071/psn-pdf
April 27, 2016 - Using simulation to identify sources of medical
diagnostic error in child physical abuse.
April 27, 2016
Anderst J, Nielsen-Parker M, Moffatt M, et al. Using simulation to identify sources of medical diagnostic
error in child physical abuse. Child Abuse Negl. 2016;52:62-69. doi:10.1016/j.chiabu.2015.12.015.
https:…
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psnet.ahrq.gov/node/47978/psn-pdf
May 01, 2019 - Patient Safety.
May 1, 2019
GMS J Med Educ. 2019;36:Doc11-Doc22.
https://psnet.ahrq.gov/issue/patient-safety-16
Patient safety has been described as an unmet need in physician training. This special issue covers areas
of focus for a patient safety curriculum drawn from experience in the German medical education sy…
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psnet.ahrq.gov/node/36225/psn-pdf
July 10, 2008 - Transfers of patient care between house staff on internal
medicine wards: a national survey.
July 10, 2008
Horwitz LI, Krumholz HM, Green M, et al. Transfers of patient care between house staff on internal
medicine wards: a national survey. Arch Intern Med. 2006;166(11):1173-7.
https://psnet.ahrq.gov/issue/transfe…
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psnet.ahrq.gov/node/37847/psn-pdf
June 18, 2008 - Effect of the 80-hour work week on resident case
coverage.
June 18, 2008
Shin S, Britt R, Britt LD. Effect of the 80-hour work week on resident case coverage. J Am Coll Surg.
2008;206(5):798-800; discussion 801-3. doi:10.1016/j.jamcollsurg.2007.12.028.
https://psnet.ahrq.gov/issue/effect-80-hour-work-week-resident…
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psnet.ahrq.gov/node/44139/psn-pdf
June 10, 2015 - In situ simulated cardiac arrest exercises to detect
system vulnerabilities.
June 10, 2015
Barbeito A, Bonifacio AS, Holtschneider M, et al. In situ simulated cardiac arrest exercises to detect system
vulnerabilities. Simul Healthc. 2015;10(3):154-62. doi:10.1097/SIH.0000000000000087.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/42109/psn-pdf
March 13, 2013 - Nursing crew resource management: a follow-up report
from the Veterans Health Administration.
March 13, 2013
Sculli GL, Fore AM, West P, et al. Nursing crew resource management: a follow-up report from the
Veterans Health Administration. J Nurs Adm. 2013;43(3):122-6. doi:10.1097/NNA.0b013e318283dafa.
https://psnet…
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psnet.ahrq.gov/node/836971/psn-pdf
April 20, 2022 - Patients should know who's operating, surgeons say.
April 20, 2022
Laber-Warren E. MedPage Today. April 5, 2022.
https://psnet.ahrq.gov/issue/patients-should-know-whos-operating-surgeons-say
Resident autonomy is an essential component to medical training, but it is not without patient safety risks.
This news artic…