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psnet.ahrq.gov/issue/increased-incidence-anesthetic-adverse-events-late-afternoon-surgeries
October 19, 2022 - Commentary
The increased incidence of anesthetic adverse events in late afternoon surgeries.
Citation Text:
Johnson J. The increased incidence of anesthetic adverse events in late afternoon surgeries. AORN J. 2008;88(1):79-87. doi:10.1016/j.aorn.2008.02.020.
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psnet.ahrq.gov/issue/spike-fatal-medication-errors-beginning-each-month
January 26, 2022 - Study
Spike in fatal medication errors at the beginning of each month.
Citation Text:
Phillips DP, Jarvinen JR, Phillips RR. A spike in fatal medication errors at the beginning of each month. Pharmacotherapy. 2005;25(1):1-9.
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psnet.ahrq.gov/issue/sleep-science-and-policy-change
September 21, 2022 - Commentary
Sleep, science, and policy change.
Citation Text:
Wylie D. Sleep, science, and policy change. N Engl J Med. 2005;352(2):196-7.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/issue/listen-carefully-risk-error-spoken-medication-orders
November 16, 2022 - Study
Listen carefully: the risk of error in spoken medication orders.
Citation Text:
Lambert BL, Dickey LW, Fisher WM, et al. Listen carefully: the risk of error in spoken medication orders. Soc Sci Med. 2010;70(10):1599-608. doi:10.1016/j.socscimed.2010.01.042.
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psnet.ahrq.gov/issue/medically-induced-trauma-support-services-mitss
December 07, 2016 - Newspaper/Magazine Article
Medically Induced Trauma Support Services (MITSS).
Citation Text:
Medically Induced Trauma Support Services (MITSS). Tobin WN. Patient Safety Quality Healthcare. May/June 2013.
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psnet.ahrq.gov/issue/national-healthcare-system-action-alliance-advance-patient-safety
April 01, 2024 - Multi-use Website
The National Healthcare System Action Alliance for Patient and Workforce Safety.
Citation Text:
The National Healthcare System Action Alliance for Patient and Workforce Safety. US Department of Health and Human Services.
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psnet.ahrq.gov/issue/accelerating-what-works-using-qualitative-research-methods-developing-change-package-learning
November 25, 2009 - Commentary
Accelerating what works: using qualitative research methods in developing a change package for a learning collaborative.
Citation Text:
Sorensen A, Bernard SL. Accelerating what works: using qualitative research methods in developing a change package for a learning collaborati…
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psnet.ahrq.gov/node/43108/psn-pdf
September 28, 2023 - Maryland Hospital Patient Safety Program Annual Report.
September 28, 2023
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.
https://psnet.ahrq.gov/issue/maryland-hospital-patient-safety-program-annual-report
This annual report summarizes never events in Maryland hospit…
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psnet.ahrq.gov/node/43468/psn-pdf
December 10, 2014 - Does compliance to patient safety tasks improve and
sustain when radiotherapy treatment processes are
standardized?
December 10, 2014
Simons P, Houben R, Benders J, et al. Does compliance to patient safety tasks improve and sustain when
radiotherapy treatment processes are standardized? Eur J Oncol Nurs. 2014;18(5…
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psnet.ahrq.gov/node/34058/psn-pdf
September 29, 2017 - Research designs for studies evaluating the effectiveness
of change and improvement strategies.
September 29, 2017
Eccles M, Grimshaw J, Campbell M, et al. Research designs for studies evaluating the effectiveness of
change and improvement strategies. Qual Saf Health Care. 2003;12(1):47-52.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/47773/psn-pdf
April 17, 2019 - People, systems and safety: resilience and excellence in
healthcare practice.
April 17, 2019
Smith AF, Plunkett E. People, systems and safety: resilience and excellence in healthcare practice.
Anaesthesia. 2019;74(4):508-517. doi:10.1111/anae.14519.
https://psnet.ahrq.gov/issue/people-systems-and-safety-resilience…
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psnet.ahrq.gov/node/44581/psn-pdf
January 20, 2016 - Quality management and perceptions of teamwork and
safety climate in European hospitals.
January 20, 2016
Kristensen S, Hammer A, Bartels P, et al. Quality management and perceptions of teamwork and safety
climate in European hospitals. Int J Qual Health Care. 2015;27(6):499-506. doi:10.1093/intqhc/mzv079.
https:/…
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psnet.ahrq.gov/node/838177/psn-pdf
September 28, 2022 - Exploring care left undone in pediatric nursing.
September 28, 2022
Bagnasco A, Rossi S, Dasso N, et al. Exploring care left undone in pediatric nursing. J Patient Saf.
2022;18(6):e903-e911. doi:10.1097/pts.0000000000001044.
https://psnet.ahrq.gov/issue/exploring-care-left-undone-pediatric-nursing
Care left undone…
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psnet.ahrq.gov/node/838146/psn-pdf
September 21, 2022 - HSIB Maternity Investigation Programme Year in Review
2021/22. Summary of Highlights, Themes and Future
Work.
September 21, 2022
Farnborough, UK: Healthcare Safety Investigation Branch; 2022.
https://psnet.ahrq.gov/issue/hsib-maternity-investigation-programme-year-review-202122-summary-
highlights-themes-and
Thi…
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psnet.ahrq.gov/node/44666/psn-pdf
August 01, 2017 - Leveraging trainees to improve quality and safety at the
point of care: three models for engagement.
August 1, 2017
Faherty LJ, Mate KS, Moses JM. Leveraging Trainees to Improve Quality and Safety at the Point of Care:
Three Models for Engagement. Acad Med. 2016;91(4):503-9. doi:10.1097/ACM.0000000000000975.
https…
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - Do Not Disturb!
October 1, 2007
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/do-not-disturb
Case Objectives
Define professionalism.
Discuss behaviors associated with lack of professionalism.
Outline steps one should take if a significant breach of professionalism is …
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psnet.ahrq.gov/node/33841/psn-pdf
September 01, 2017 - In Conversation With… Andrew Gettinger, MD
September 1, 2017
In Conversation With… Andrew Gettinger, MD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
Editor's note: Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the
Office of Cli…
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psnet.ahrq.gov/node/33704/psn-pdf
December 01, 2010 - In Conversation with...Geri Amori, PhD
December 1, 2010
In Conversation with..Geri Amori, PhD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
Editor's note: Geri Amori, PhD, is Vice President for the Education Center at The Risk Management and
Patient Safety Institute, a…
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psnet.ahrq.gov/node/46207/psn-pdf
July 19, 2017 - Burnout Among Health Care Professionals. A Call to
Explore and Address This Underrecognized Threat to
Safe, High-Quality Care.
July 19, 2017
Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Washington, DC: National Academy of Medicine; July 5, 2017.
https://psnet.ahrq.gov/issue/burnout-among-health-care-professionals-ca…
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psnet.ahrq.gov/node/33923/psn-pdf
June 12, 2018 - The collapse of sensemaking in organizations: the Mann
Gulch disaster.
June 12, 2018
Weick KE. The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster. Admin Sci Q.
2006;38(4):628-652. doi:10.2307/2393339.
https://psnet.ahrq.gov/issue/collapse-sensemaking-organizations-mann-gulch-disaster
This artic…