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Blanco M, Clarke JR, Martindell D. AORN J. 2009;90:215-222.
Blanco M ; Clarke JR ; Martindell D.Wrong site surgery near misses and actual occurrences. AORN J. 2009; 90: 215-222
This analysis of wrong-site surgery cases and near misses reported to the Pennsylvania Patient Safety Authority found that many cases involved failure to follow The Joint Commission's Universal Protocol for preventing such errors.
Wrong body part, wrong patient surgeries continue despite new procedures.
Rojas-Burke J. The Oregonian. May 25, 2011.
Process changes to increase compliance with the Universal Protocol for bedside procedures.
Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.
Wrong-patient, wrong-site procedures persist despite safety protocol.
O'Reilly KB. American Medical News; Nov. 1, 2010.
Hospitals collaborate to prevent wrong-site surgery.
Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.
Determining the state of knowledge for implementing the Universal Protocol recommendations: an integrative review of the literature.
Conrardy JA, Brenek B, Myers S. AORN J. 2010;92:194-207.
Wrong-site craniotomy: analysis of 35 cases and systems for prevention.
Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473.
Surgical site signing and "time out": issues of compliance or complacence.
Johnston G, Ekert L, Pally E. J Bone Joint Surg Am. 2009;91:2577-2580.
Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands.
Vanhaecht K, Seys D, Schouten L, et al; Dutch Peer Support Collaborative Research Group. BMJ Open. 2019;9:e029923.
Information flow during pediatric trauma care transitions: things falling through the cracks.
Hoonakker PLT, Wooldridge AR, Hose BZ, et al. Intern Emerg Med. 2019;14:797-805.
Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: a systematic review.
Higham H, Greig PR, Rutherford J, Vincent L, Young D, Vincent C. BMJ Qual Saf. 2019;28:672-686.
How one health system overcame resistance to a surgical checklist.
Hilton K, Anderson A. Harv Bus Rev. May 20, 2019.
What has an Airbus A380 captain got to do with OMFS? Lessons from aviation to improve patient safety.
Davidson M, Brennan PA. Br J Oral Maxillofac Surg. 2019;57:407-411.
Safety in the Prehospital Emergency Medical Services Setting
P. Daniel Patterson, PhD, NRP, and Donald M. Yealy, MD
Health systems and hospitals in pursuit of high reliability.
Cheney C. HealthLeaders Media. April 17, 2019.
The admission conference call: a novel approach to optimizing pediatric emergency department to admitting floor communication.
Hendrickson MA, Schempf EN, Furnival RA, Marmet J, Lunos SA, Jacob AK. Jt Comm J Qual Patient Saf. 2019;45:431-439.
A team disclosure of error educational activity: objective outcomes.
Krumwiede KH, Wagner JM, Kirk LM, et al. J Am Geriatr Soc. 2019;67:1273-1277.
The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes.
Casali G, Cullen W, Lock G. J Thorac Dis. 2019;11(suppl 7):S998-S1008.
Incivility and patient safety: a longitudinal study of rudeness, protocol compliance, and adverse events.
Riskin A, Bamberger P, Erez A, et al. Jt Comm J Qual Patient Saf. 2019;45:358-367.
Achieving dialysis safety: the critical role of higher-functioning teams.
Wong LP. Semin Dial. 2019;32:266-273.
Patient Safety Essentials Toolkit.
Boston, MA: Institute for Healthcare Improvement; 2019.
How to deliver safer and effective patient care: tips for team leaders and educators.
Shah BJ. Gastroenterology. 2019;156:852-855.
Teamwork—Part 1: Divided We Fall; Part 2: Cursed By Knowledge—Building a Culture of Psychological Safety; and Part 3: The Not-My-Problem Problem.
Rosenbaum L. N Engl J Med. 2019;380:684-688;786-790;881-885.
A qualitative positive deviance study to explore exceptionally safe care on medical wards for older people.
Baxter R, Taylor N, Kellar I, Lawton R. BMJ Qual Saf. 2019 Feb 13; [Epub ahead of print].
The impact of mobile technology on teamwork and communication in hospitals: a systematic review.
Martin G, Khajuria A, Arora S, King D, Ashrafian H, Darzi A. J Am Med Inform Assoc. 2019;26:339-355.
Balancing patient-centered and safe pain care for nonsurgical inpatients: clinical and managerial perspectives.
Mazurenko O, Andraka-Christou BT, Bair MJ, Kara AY, Harle CA. Jt Comm J Qual Patient Saf. 2019;45:241–248.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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