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psnet.ahrq.gov/node/73171/psn-pdf
April 21, 2021 - Patient safety and quality improvement adaptation during
the COVID-19 pandemic.
April 21, 2021
Sterling RS, Berry SA, Herzke C, et al. Patient safety and quality improvement adaptation during the
COVID-19 pandemic. Am J Med Qual. 2021;36(1):57-59. doi:10.1097/01.jmq.0000733448.50484.a8.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/47016/psn-pdf
June 25, 2018 - U.S. Food and Drug Administration Precertification pilot
program for digital health software: weighing the benefits
and risks.
June 25, 2018
Lee TT, Kesselheim AS. U.S. Food and Drug Administration Precertification Pilot Program for Digital Health
Software: Weighing the Benefits and Risks. Ann Intern Med. 2018;168…
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psnet.ahrq.gov/node/74183/psn-pdf
December 15, 2021 - Identifying safe care processes when GPs work in or
alongside emergency departments: a realist evaluation.
December 15, 2021
Cooper A, Carson-Stevens A, Edwards M, et al. Identifying safe care processes when GPs work in or
alongside emergency departments: a realist evaluation. Br J Gen Pract. 2021;71(713):e931-e940…
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psnet.ahrq.gov/node/853619/psn-pdf
September 20, 2023 - Defining speaking up in the healthcare system: a
systematic review.
September 20, 2023
Kane J, Munn L, Kane SF, et al. Defining speaking up in the healthcare system: a systematic review. J Gen
Intern Med. 2023;38(15):3406-3413. doi:10.1007/s11606-023-08322-0.
https://psnet.ahrq.gov/issue/defining-speaking-healthca…
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psnet.ahrq.gov/node/47184/psn-pdf
August 08, 2018 - Delivering on the promise of CLER: a patient safety
rotation that aligns resident education with hospital
processes.
August 8, 2018
Patel E, Muthusamy V, Young JQ. Delivering on the Promise of CLER: A Patient Safety Rotation That
Aligns Resident Education With Hospital Processes. Acad Med. 2018;93(6):898-903.
doi…
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psnet.ahrq.gov/node/47907/psn-pdf
July 19, 2019 - Safety-I, Safety-II and burnout: how complexity science
can help clinician wellness.
July 19, 2019
Smaggus A. Safety-I, Safety-II and burnout: how complexity science can help clinician wellness. BMJ Qual
Saf. 2019;28(8):667-671. doi:10.1136/bmjqs-2018-009147.
https://psnet.ahrq.gov/issue/safety-i-safety-ii-and-bur…
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psnet.ahrq.gov/node/44228/psn-pdf
September 04, 2016 - Bridging the gap: a framework and strategies for
integrating the quality and safety mission of teaching
hospitals and graduate medical education.
September 4, 2016
Tess A, Vidyarthi A, Yang J, et al. Bridging the Gap: A Framework and Strategies for Integrating the Quality
and Safety Mission of Teaching Hospitals a…
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psnet.ahrq.gov/node/48108/psn-pdf
July 10, 2019 - Patterns of opioid administration among opioid-naive
inpatients and associations with postdischarge opioid
use: a cohort study.
July 10, 2019
Donohue JM, Kennedy JN, Seymour CW, et al. Patterns of Opioid Administration Among Opioid-Naive
Inpatients and Associations With Postdischarge Opioid Use: A Cohort Study. An…
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psnet.ahrq.gov/node/38014/psn-pdf
March 02, 2011 - The frequency and significance of discrepancies in the
surgical count.
March 2, 2011
Greenberg CC, Regenbogen SE, Lipsitz SR, et al. The Frequency and Significance of Discrepancies in the
Surgical Count. Ann Surg. 2009;248(2). doi:10.1097/sla.0b013e318181c9a3.
https://psnet.ahrq.gov/issue/frequency-and-significanc…
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psnet.ahrq.gov/node/45348/psn-pdf
September 14, 2016 - Integrating teamwork, clinician occupational well-being
and patient safety—development of a conceptual
framework based on a systematic review.
September 14, 2016
Welp A, Manser T. Integrating teamwork, clinician occupational well-being and patient safety - development
of a conceptual framework based on a systemati…
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psnet.ahrq.gov/node/50795/psn-pdf
January 15, 2020 - Diagnostic error in the emergency department: learning
from national patient safety incident report analysis.
January 15, 2020
Hussain F, Cooper A, Carson-Stevens A, et al. Diagnostic error in the emergency department: learning
from national patient safety incident report analysis. BMC Emerg Med. 2019;19(1):77. doi…
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psnet.ahrq.gov/node/37131/psn-pdf
October 04, 2011 - Supplemental nurse staffing in hospitals and quality of
care.
October 4, 2011
Aiken LH, Xue Y, Clarke SP, et al. Supplemental Nurse Staffing in Hospitals and Quality of Care. JONA:
The Journal of Nursing Administration. 2007;37(7). doi:10.1097/01.nna.0000285119.53066.ae.
https://psnet.ahrq.gov/issue/supplemental-n…
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psnet.ahrq.gov/node/43808/psn-pdf
April 22, 2015 - Preventing iatrogenic overdose: a review of
in–emergency department opioid-related adverse drug
events and medication errors.
April 22, 2015
Beaudoin FL, Merchant RC, Janicki A, et al. Preventing iatrogenic overdose: a review of in-emergency
department opioid-related adverse drug events and medication errors. Ann …
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psnet.ahrq.gov/node/50945/psn-pdf
February 26, 2020 - She hoped to shine a light on maternal mortality among
Native Americans. Instead, she became a statistic of it.
February 26, 2020
Chuck E, Assefa H. NBC News. February 8, 2020.
https://psnet.ahrq.gov/issue/she-hoped-shine-light-maternal-mortality-among-native-americans-instead-
she-became-statistic
Maternal morbi…
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psnet.ahrq.gov/node/37448/psn-pdf
January 06, 2017 - Patient safety rounds in a pediatric tertiary care center.
January 6, 2017
Rinke ML, Zimmer KP, Lehmann CU, et al. Patient safety rounds in a pediatric tertiary care center. Jt
Comm J Qual Patient Saf. 2008;34(1):5-12.
https://psnet.ahrq.gov/issue/patient-safety-rounds-pediatric-tertiary-care-center
Executive walk…
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psnet.ahrq.gov/node/866117/psn-pdf
January 01, 2025 - Diagnostic disparities and strategies for enhancing
diagnostic equity in hospital medicine.
June 12, 2024
Raffel KE, Gershanik EF, Ranji SR. Diagnostic disparities and strategies for enhancing diagnostic equity in
hospital medicine. J Hosp Med. 2025;20(1):71-74. doi:10.1002/jhm.13375.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/72856/psn-pdf
March 17, 2021 - The fusion of incident learning and failure mode and
effects analysis for data-driven patient safety
improvements.
March 17, 2021
Paradis KC, Naheedy KW, Matuszak MM, et al. The fusion of incident learning and failure mode and
effects analysis for data-driven patient safety improvements. Pract Radiat Oncol. 2020;1…
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psnet.ahrq.gov/node/43809/psn-pdf
February 25, 2015 - Application of the aviation black box principle in pediatric
cardiac surgery: tracking all failures in the pediatric
cardiac operating room.
February 25, 2015
Bowermaster R, Miller M, Ashcraft T, et al. Application of the aviation black box principle in pediatric
cardiac surgery: tracking all failures in the pedia…
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psnet.ahrq.gov/node/46623/psn-pdf
July 02, 2019 - Factors contributing to medication errors made when
using computerized order entry in pediatrics: a
systematic review.
July 2, 2019
Tolley CL, Forde NE, Coffey KL, et al. Factors contributing to medication errors made when using
computerized order entry in pediatrics: a systematic review. J Am Med Info Assoc. 2017…
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psnet.ahrq.gov/node/34680/psn-pdf
February 09, 2011 - Estimating hospital deaths due to medical errors:
preventability is in the eye of the reviewer.
February 9, 2011
Hayward RA, Hofer TP. Estimating hospital deaths due to medical errors: preventability is in the eye of the
reviewer. JAMA. 2001;286(4):415-20.
https://psnet.ahrq.gov/issue/estimating-hospital-deaths-du…