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psnet.ahrq.gov/node/46957/psn-pdf
May 17, 2018 - Improving communication with patients with limited
English proficiency.
May 17, 2018
Taira BR. Improving Communication With Patients With Limited English Proficiency. JAMA Int Med.
2018;178(5):605-606. doi:10.1001/jamainternmed.2018.0373.
https://psnet.ahrq.gov/issue/improving-communication-patients-limited-englis…
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psnet.ahrq.gov/node/43962/psn-pdf
December 04, 2015 - Undergraduate baccalaureate nursing students' self-
reported confidence in learning about patient safety in the
classroom and clinical settings: an annual cross-
sectional study (2010–2013).
December 4, 2015
Lukewich J, Edge DS, Tranmer J, et al. Undergraduate baccalaureate nursing students' self-reported
confide…
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psnet.ahrq.gov/node/846708/psn-pdf
March 29, 2023 - Anesthesiology patient handoff education interventions: a
systematic review.
March 29, 2023
Riesenberg LA, Davis R, Heng A, et al. Anesthesiology patient handoff education interventions: a
systematic review. Jt Comm J Qual Patient Saf. 2023;49(8):394-404. doi:10.1016/j.jcjq.2022.12.002.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/40063/psn-pdf
March 04, 2011 - Challenges in ethics, safety, best practices, and oversight
regarding HIT vendors, their customers, and patients: a
report of an AMIA special task force.
March 4, 2011
Goodman KW, Berner ES, Dente MA, et al. Challenges in ethics, safety, best practices, and oversight
regarding HIT vendors, their customers, and pat…
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psnet.ahrq.gov/node/35909/psn-pdf
October 07, 2008 - Committed to Safety: Ten Case Studies on Reducing
Harm to Patients.
October 7, 2008
McCarthy D, Blumenthal D. New York, NY: Commonwealth Fund; 2006.
https://psnet.ahrq.gov/issue/committed-safety-ten-case-studies-reducing-harm-patients
This report presents ten case studies to illustrate interventions that address p…
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psnet.ahrq.gov/node/38448/psn-pdf
March 04, 2009 - Medication errors: the impact of prescribing and
transcribing errors on preventable harm in hospitalised
patients.
March 4, 2009
van Doormaal JE, van den Bemt PMLA, Mol PGM, et al. Medication errors: the impact of prescribing and
transcribing errors on preventable harm in hospitalised patients. Qual Saf Health Car…
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psnet.ahrq.gov/node/46658/psn-pdf
April 18, 2018 - Safer healthcare at home: detecting, correcting and
learning from incidents involving infusion devices.
April 18, 2018
Lyons I, Blandford A. Safer healthcare at home: detecting, correcting and learning from incidents involving
infusion devices. App Ergon. 2018;67(Feb):104-114. doi:10.1016/j.apergo.2017.09.010.
htt…
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psnet.ahrq.gov/node/45977/psn-pdf
May 17, 2017 - Trends in medical and nonmedical use of prescription
opioids among US adolescents: 1976–2015.
May 17, 2017
McCabe SE, West BT, Veliz P, et al. Trends in Medical and Nonmedical Use of Prescription Opioids
Among US Adolescents: 1976-2015. Pediatrics. 2017;139(4):e20162387. doi:10.1542/peds.2016-2387.
https://psnet.a…
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psnet.ahrq.gov/node/47423/psn-pdf
January 27, 2019 - A health system–wide initiative to decrease opioid-related
morbidity and mortality.
January 27, 2019
Weiner SG, Price CN, Atalay AJ, et al. A Health System-Wide Initiative to Decrease Opioid-Related
Morbidity and Mortality. Jt Comm J Qual Patient Saf. 2019;45(1):3-13. doi:10.1016/j.jcjq.2018.07.003.
https://psnet.…
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psnet.ahrq.gov/node/50848/psn-pdf
January 29, 2020 - Deficiencies in Care Coordination and Facility Response
to a Patient Suicide at the Minneapolis VA Health Care
System, Minnesota.
January 29, 2020
Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 7, 2020. Report No.
19-00468-67.
https://psnet.ahrq.gov/issue/deficiencies-care-co…
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psnet.ahrq.gov/node/867097/psn-pdf
November 06, 2024 - Recommendations but no Action: Improving the
Effectiveness of Quality and Safety Recommendations in
Healthcare.
November 6, 2024
Recommendations But No Action: Improving The Effectiveness Of Quality And Safety Recommendations
In Healthcare. Dorset, UK: Health Services Safety Investigations Body; September 2024.
h…
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psnet.ahrq.gov/node/44493/psn-pdf
September 19, 2016 - Interventions in health organisations to reduce the impact
of adverse events in second and third victims.
September 19, 2016
Mira JJ, Lorenzo S, Carrillo I, et al. Interventions in health organisations to reduce the impact of adverse
events in second and third victims. BMC Health Serv Res. 2015;15:341. doi:10.1186/…
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psnet.ahrq.gov/node/60261/psn-pdf
April 22, 2020 - Hospital Experiences Responding to the COVID-19
Pandemic: Results of a National Pulse Survey March 23-
27, 2020.
April 22, 2020
Washington DC: Office of the Inspector General; April 3, 2020. Report no. OEI-06-20-00300.
https://psnet.ahrq.gov/issue/hospital-experiences-responding-covid-19-pandemic-results-national-…
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psnet.ahrq.gov/node/36795/psn-pdf
August 26, 2011 - Surgical specimen identification errors: a new measure of
quality in surgical care.
August 26, 2011
Makary MA, Epstein J, Pronovost P, et al. Surgical specimen identification errors: a new measure of quality
in surgical care. Surgery. 2007;141(4):450-5.
https://psnet.ahrq.gov/issue/surgical-specimen-identification…
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psnet.ahrq.gov/node/44898/psn-pdf
November 23, 2016 - Types and patterns of safety concerns in home care:
client and family caregiver perspectives.
November 23, 2016
Tong CE, Sims-Gould J, Martin-Matthews A. Types and patterns of safety concerns in home care: client
and family caregiver perspectives. Int J Qual Health Care. 2016;28(2):214-220.
doi:10.1093/intqhc/mzw0…
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psnet.ahrq.gov/node/43958/psn-pdf
April 22, 2015 - Non-intercepted dose errors in prescribing antineoplastic
treatment: a prospective, comparative cohort study.
April 22, 2015
Mattsson TO, Holm B, Michelsen H, et al. Non-intercepted dose errors in prescribing anti-neoplastic
treatment: a prospective, comparative cohort study. Ann Oncol. 2015;26(5):981-6.
doi:10.10…
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psnet.ahrq.gov/node/34803/psn-pdf
January 05, 2017 - Systematic root cause analysis of adverse drug events in
a tertiary referral hospital.
January 5, 2017
Rex JH, Turnbull JE, Allen SJ, et al. Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary
Referral Hospital. Jt Comm J Qual Improv. 2016;26(10). doi:10.1016/s1070-3241(00)26048-3.
https://psnet.ah…
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psnet.ahrq.gov/node/866645/psn-pdf
September 04, 2024 - Technology-related safety event analysis in community
clinical informatics: a case study.
September 4, 2024
Recsky C, Stowe M, Rush KL, et al. Technology-related safety event analysis in community clinical
informatics: a case study. Stud Health Technol Inform. 2024;315:452-457. doi:10.3233/shti240189.
https://psne…
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psnet.ahrq.gov/node/844768/psn-pdf
September 11, 2019 - Standardized orders for titrating vasopressors: do efforts
to improve safety slow delivery of care?
September 11, 2019
Baker DW, Campbell R. Standardized Orders for Titrating Vasopressors: Do Efforts to Improve Safety Slow
Delivery of Care? Jt Comm J Qual Patient Saf. 2019;45(9):589-590. doi:10.1016/j.jcjq.2019.07.…
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psnet.ahrq.gov/node/43480/psn-pdf
January 01, 2015 - Speaking up: factors and issues in nurses advocating for
patients when patients are in jeopardy.
December 15, 2014
Rainer J. Speaking up: factors and issues in nurses advocating for patients when patients are in jeopardy.
J Nurs Care Qual. 2015;30(1):53-62. doi:10.1097/NCQ.0000000000000081.
https://psnet.ahrq.gov/…