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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/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…
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psnet.ahrq.gov/node/47893/psn-pdf
April 08, 2019 - Challenges with implementing the Centers for Disease
Control and Prevention opioid guideline: a consensus
panel report.
April 8, 2019
Kroenke K, Alford DP, Argoff C, et al. Challenges with Implementing the Centers for Disease Control and
Prevention Opioid Guideline: A Consensus Panel Report. Pain Med. 2019;20(4):7…
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psnet.ahrq.gov/node/38722/psn-pdf
June 24, 2009 - Why do people sue doctors? A study of patients and
relatives taking legal action.
June 24, 2009
Vincent C, Young M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal
action. Lancet. 1994;343(8913):1609-1613.
https://psnet.ahrq.gov/issue/why-do-people-sue-doctors-study-patients-a…
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psnet.ahrq.gov/node/34949/psn-pdf
June 23, 2009 - A randomized, controlled trial evaluating the impact of a
computerized rounding and sign-out system on continuity
of care and resident work hours.
June 23, 2009
Van Eaton EG, Horvath KD, Lober WB, et al. A randomized, controlled trial evaluating the impact of a
computerized rounding and sign-out system on continui…
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psnet.ahrq.gov/node/35467/psn-pdf
March 11, 2011 - The impact of electronic health records on time efficiency
of physicians and nurses: a systematic review.
March 11, 2011
Poissant L, Pereira J, Tamblyn R, et al. The impact of electronic health records on time efficiency of
physicians and nurses: a systematic review. J Am Med Inform Assoc. 2005;12(5):505-16.
https…
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psnet.ahrq.gov/node/46627/psn-pdf
January 30, 2018 - The lost art of doctoring: reflections of a pediatric
resident.
January 30, 2018
Mitchell SM. The Lost Art of Doctoring: Reflections of a Pediatric Resident. JAMA Pediatr. 2018;172(1):10.
doi:10.1001/jamapediatrics.2017.3247.
https://psnet.ahrq.gov/issue/lost-art-doctoring-reflections-pediatric-resident
There are…
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psnet.ahrq.gov/node/44237/psn-pdf
November 03, 2015 - Surgical never events and contributing human factors.
November 3, 2015
Thiels CA, Lal TM, Nienow JM, et al. Surgical never events and contributing human factors. Surgery.
2015;158(2):515-21. doi:10.1016/j.surg.2015.03.053.
https://psnet.ahrq.gov/issue/surgical-never-events-and-contributing-human-factors
Never even…
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psnet.ahrq.gov/node/38470/psn-pdf
March 11, 2009 - Quality and strength of patient safety climate on
medical–surgical units.
March 11, 2009
Hughes LC, Chang YK, Mark BA. Quality and strength of patient safety climate on medical-surgical units.
Health Care Manag Rev. 2009;34(1):19-28. doi:10.1097/01.HMR.0000342976.07179.3a.
https://psnet.ahrq.gov/issue/quality-and-…
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psnet.ahrq.gov/node/44158/psn-pdf
September 30, 2015 - Meaningful Use stage 2 e-prescribing threshold and
adverse drug events in the Medicare Part D population
with diabetes.
September 30, 2015
Powers C, Gabriel MH, Encinosa W, et al. Meaningful use stage 2 e-prescribing threshold and adverse
drug events in the Medicare Part D population with diabetes. J Am Med Inform…
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psnet.ahrq.gov/node/865971/psn-pdf
May 29, 2024 - Lessons learned from a national hospital antibiotic
stewardship implementation project.
May 29, 2024
Cosgrove SE, Ahn R, Dullabh P, et al. Lessons learned from a national hospital antibiotic stewardship
implementation project. Jt Comm J Qual Patient Saf. 2024;50(6):435-441. doi:10.1016/j.jcjq.2024.04.002.
https://…
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psnet.ahrq.gov/node/73537/psn-pdf
July 28, 2021 - Health literacy-related safety events: a qualitative study of
health literacy failures in patient safety events.
July 28, 2021
Morrison AK, Gibson C, Higgins C, et al. Health literacy-related safety events: a qualitative study of health
literacy failures in patient safety events. Pediatr Qual Saf. 2021;6(4):e425.
…
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psnet.ahrq.gov/node/37590/psn-pdf
April 13, 2018 - Just Culture: Restoring Trust and Accountability in Your
Organization, Third Edition.
April 13, 2018
Dekker S. Boca Raton, FL: CRC Press; 2017. ISBN: 9781472475756.
https://psnet.ahrq.gov/issue/just-culture-restoring-trust-and-accountability-your-organization-third-edition
Although early efforts in the patient saf…
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psnet.ahrq.gov/node/41556/psn-pdf
January 03, 2017 - Patient safety reporting systems: sustained quality
improvement using a multidisciplinary team and "Good
Catch" awards.
January 3, 2017
Herzer KR, Mirrer M, Xie Y, et al. Patient Safety Reporting Systems: Sustained Quality Improvement Using
a Multidisciplinary Team and “Good Catch” Awards. Jt Comm J Qual Patient S…
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psnet.ahrq.gov/node/45602/psn-pdf
February 20, 2017 - Ethical considerations in the development of the
Flexibility in Duty Hour Requirements for Surgical
Trainees trial.
February 20, 2017
Minami CA, Odell DD, Bilimoria KY. Ethical Considerations in the Development of the Flexibility in Duty
Hour Requirements for Surgical Trainees Trial. JAMA Surg. 2017;152(1):7-8.
d…
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psnet.ahrq.gov/node/46756/psn-pdf
May 09, 2018 - Using a modified A3 lean framework to identify ways to
increase students' reporting of mistreatment behaviors.
May 9, 2018
Ross PT, Abdoler E, Flygt LA, et al. Using a Modified A3 Lean Framework to Identify Ways to Increase
Students' Reporting of Mistreatment Behaviors. Acad Med. 2018;93(4):606-611.
doi:10.1097/AC…
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psnet.ahrq.gov/node/74691/psn-pdf
January 01, 2021 - U.S. Department of Veterans Affairs Medical Center,
Houston, TX, and Baylor College of Medicine Revised
Safer Diagnosis (Safer Dx) Instrument
January 26, 2022
https://psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-
college-medicine
Summary
The Revised Safer Dx Instr…
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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart
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June 12, 2020
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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - SPOTLIGHT CASE
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.
Citation Text:
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.. PSNet [internet]. Rockville (MD):…
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psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
February 26, 2025 - U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument
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