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psnet.ahrq.gov/node/45914/psn-pdf
March 20, 2018 - Understanding the multidimensional effects of resident
duty hours restrictions: a thematic analysis of published
viewpoints in surgery.
March 20, 2018
Devitt KS, Kim MJ, Conn LG, et al. Understanding the Multidimensional Effects of Resident Duty Hours
Restrictions: A Thematic Analysis of Published Viewpoints in Su…
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psnet.ahrq.gov/node/46981/psn-pdf
May 04, 2019 - Lessons learned from implementing a principled
approach to resolution following patient harm.
May 4, 2019
Smith KM, Smith LL, (Jack) Gentry JC, et al. Lessons learned from implementing a principled approach to
resolution following patient harm. J Patient Saf Risk Manag. 2018;24(2):83-89.
doi:10.1177/25160435188138…
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psnet.ahrq.gov/node/42419/psn-pdf
July 17, 2013 - Health IT Patient Safety Action and Surveillance Plan.
July 17, 2013
Washington, DC: Office of the National Coordinator for Health Information Technology; July 2, 2013.
https://psnet.ahrq.gov/issue/health-it-patient-safety-action-and-surveillance-plan
This report from the Department of Health and Human Services (HH…
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psnet.ahrq.gov/node/45700/psn-pdf
September 01, 2018 - Resolving malpractice claims after tort reform: experience
in a self-insured Texas public academic health system.
September 1, 2018
Sage WM, Harding MC, Thomas EJ. Resolving Malpractice Claims after Tort Reform: Experience in a Self-
Insured Texas Public Academic Health System. Health Serv Res. 2016;51 Suppl 3:2615…
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psnet.ahrq.gov/node/60194/psn-pdf
April 01, 2020 - Do you know what doses are being programmed in the
OR? Make it an expectation to use smart infusion pumps
with DERS.
April 1, 2020
Do you know what doses are being programmed in the OR? Make it an expectation to use smart infusion
pumps with DERS. ISMP Medication Safety Alert! Acute care edition!. 25(5):1-5.
http…
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psnet.ahrq.gov/node/42149/psn-pdf
December 23, 2016 - Medical device alarm safety in hospitals.
December 23, 2016
Medical device alarm safety in hospitals. Sentinel event alert. 2013;(50):1-3.
https://psnet.ahrq.gov/issue/medical-device-alarm-safety-hospitals
The cacophony of alarms in hospitals has led many health care providers to become desensitized to them,
a con…
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psnet.ahrq.gov/node/37849/psn-pdf
March 23, 2011 - The incidence and nature of in-hospital adverse events: a
systematic review.
March 23, 2011
de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse
events: a systematic review. Qual Saf Health Care. 2008;17(3):216-223. doi:10.1136/qshc.2007.023622.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/44692/psn-pdf
January 27, 2016 - Good people who try their best can have problems:
recognition of human factors and how to minimise error.
January 27, 2016
Brennan PA, Mitchell DA, Holmes S, et al. Good people who try their best can have problems: recognition
of human factors and how to minimise error. Br J Oral Maxillofac Surg. 2016;54(1):3-7.
d…
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psnet.ahrq.gov/node/43205/psn-pdf
April 04, 2018 - Placing Diagnosis Errors on the Policy Agenda.
April 4, 2018
Berenson RA, Upadhyay D, Kaye DR. Washington, DC: Urban Institute. Princeton, NJ: Robert Wood
Johnson Foundation; 2014.
https://psnet.ahrq.gov/issue/placing-diagnosis-errors-policy-agenda
This comprehensive policy brief emphasizes the importance of addre…
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psnet.ahrq.gov/node/42484/psn-pdf
August 14, 2013 - Parent willingness to remind health care workers to
perform hand hygiene.
August 14, 2013
Buser GL, Fisher BT, Shea JA, et al. Parent willingness to remind health care workers to perform hand
hygiene. Am J Infect Control. 2013;41(6):492-6. doi:10.1016/j.ajic.2012.08.006.
https://psnet.ahrq.gov/issue/parent-willing…
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psnet.ahrq.gov/node/840147/psn-pdf
November 16, 2022 - Electronic diagnostic support in emergency physician
triage: qualitative study with thematic analysis of
interviews.
November 16, 2022
Sibbald M, Abdulla B, Keuhl A, et al. Electronic diagnostic support in emergency physician triage:
qualitative study with thematic analysis of interviews. JMIR Hum Factors. 2022;9(…
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psnet.ahrq.gov/node/843417/psn-pdf
February 01, 2023 - "Do no harm": promoting anti-racist policing in pediatric
emergency departments through 20 practice change
considerations.
February 1, 2023
Wells JM, Walker VP. "Do no harm": promoting anti-racist policing in pediatric emergency departments
through 20 practice change considerations. Health Promot Pract. 2023:15248…
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psnet.ahrq.gov/node/45458/psn-pdf
November 30, 2016 - Request for comments on the proposed measures and
2020 targets for the National Action Plan for Adverse Drug
Event Prevention: inpatient and outpatient measures for
reduction of adverse drug events from anticoagulants,
diabetes agents, and opioid analgesics.
November 30, 2016
Office of Disease Prevention and Heal…
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psnet.ahrq.gov/node/60540/psn-pdf
November 01, 2016 - Quality improvement initiatives lead to reduction in
nulliparous term singleton vertex cesarean delivery rate.
November 1, 2016
Vadnais MA, Hacker MR, Shah NT, et al. Quality improvement initiatives lead to reduction in nulliparous
term singleton vertex cesarean delivery rate. Jt Comm J Qual Patient Saf. 2016;43(2)…
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psnet.ahrq.gov/node/862994/psn-pdf
February 21, 2024 - Impact of the primary care nurse manager on nurse intent
to leave and staff perception of patient safety.
February 21, 2024
Miller MJ, Johansen ML, de Cordova PB, et al. Impact of the primary care nurse manager on nurse intent
to leave and staff perception of patient safety. Nurs Manage. 2024;55(1):32-42.
doi:10.1…
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psnet.ahrq.gov/node/41054/psn-pdf
January 27, 2012 - The impact of nontechnical skills on technical
performance in surgery: a systematic review.
January 27, 2012
Hull L, Arora S, Aggarwal R, et al. The impact of nontechnical skills on technical performance in surgery: a
systematic review. J Am Coll Surg. 2012;214(2):214-230. doi:10.1016/j.jamcollsurg.2011.10.016.
ht…
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psnet.ahrq.gov/node/45091/psn-pdf
February 14, 2017 - The interplay between teamwork, clinicians' emotional
exhaustion, and clinician-rated patient safety: a
longitudinal study.
February 14, 2017
Welp A, Meier LL, Manser T. The interplay between teamwork, clinicians' emotional exhaustion, and
clinician-rated patient safety: a longitudinal study. Crit Care. 2016;20(1)…
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psnet.ahrq.gov/node/40841/psn-pdf
October 16, 2012 - How dangerous is a day in hospital?: A model of adverse
events and length of stay for medical inpatients.
October 16, 2012
Hauck K, Zhao X. How dangerous is a day in hospital? A model of adverse events and length of stay for
medical inpatients. Med Care. 2011;49(12):1068-75. doi:10.1097/MLR.0b013e31822efb09.
https…
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psnet.ahrq.gov/node/74839/psn-pdf
February 16, 2022 - Impact of unacceptable behaviour between healthcare
workers on clinical performance and patient outcomes: a
systematic review.
February 16, 2022
Guo L, Ryan B, Leditschke IA, et al. Impact of unacceptable behaviour between healthcare workers on
clinical performance and patient outcomes: a systematic review. BMJ Qu…
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psnet.ahrq.gov/node/35407/psn-pdf
September 11, 2009 - Liability reform should make patients safer: "Avoidable
classes of events" are a key improvement.
September 11, 2009
Bovbjerg RR, Tancredi LR. Liability reform should make patients safer: "avoidable classes of events" are a
key improvement. J Law Med Ethics. 2005;33(3):478-500.
https://psnet.ahrq.gov/issue/liabili…