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psnet.ahrq.gov/node/42387/psn-pdf
December 30, 2014 - 'Bad apples': time to redefine as a type of systems
problem?
December 30, 2014
Shojania KG, Dixon-Woods M. 'Bad apples': time to redefine as a type of systems problem? BMJ Qual Saf.
2013;22(7):528-531. doi:10.1136/bmjqs-2013-002138.
https://psnet.ahrq.gov/issue/bad-apples-time-redefine-type-systems-problem
While …
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psnet.ahrq.gov/node/866934/psn-pdf
October 09, 2024 - How America’s health care system fails women in pain.
October 9, 2024
Neklason A. How America’s health care system fails women in pain. The Hill. September 23, 2024;
https://psnet.ahrq.gov/issue/how-americas-health-care-system-fails-women-pain
Appropriate treatment of pain is a complicated process vulnerable to rac…
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psnet.ahrq.gov/node/46332/psn-pdf
September 24, 2017 - Sharing the process of diagnostic decision making.
September 24, 2017
Brush JE, Brophy JM. Sharing the Process of Diagnostic Decision Making. JAMA Intern Med.
2017;177(9):1245-1246. doi:10.1001/jamainternmed.2017.1929.
https://psnet.ahrq.gov/issue/sharing-process-diagnostic-decision-making
Improving diagnosis has …
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psnet.ahrq.gov/node/38846/psn-pdf
August 05, 2009 - Seeking a safer surgery: some states crack down on
doctors who perform unregulated outpatient procedures.
August 5, 2009
Landro L.
https://psnet.ahrq.gov/issue/seeking-safer-surgery-some-states-crack-down-doctors-who-perform-
unregulated-outpatient
This article discusses growing legal oversight on outpatient surg…
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psnet.ahrq.gov/node/38405/psn-pdf
February 11, 2009 - Development of a self-report instrument to measure
patient safety attitudes, skills, and knowledge.
February 11, 2009
Schnall R, Stone PW, Currie L, et al. Development of a self-report instrument to measure patient safety
attitudes, skills, and knowledge. J Nurs Scholarsh. 2008;40(4):391-4. doi:10.1111/j.1547-
506…
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psnet.ahrq.gov/node/38592/psn-pdf
April 29, 2009 - The teaching of a structured tool improves the clarity and
content of interprofessional clinical communication.
April 29, 2009
Marshall S, Harrison J, Flanagan B. The teaching of a structured tool improves the clarity and content of
interprofessional clinical communication. Qual Saf Health Care. 2009;18(2):137-40.
…
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psnet.ahrq.gov/node/35982/psn-pdf
September 17, 2010 - Follow-up study of medication errors reported to the
Vaccine Adverse Event Reporting System (VAERS).
September 17, 2010
Varricchio F, Reed J, Group VAERSW. Follow-up study of medication errors reported to the vaccine
adverse event reporting system (VAERS). South Med J. 2006;99(5):486-9.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/60671/psn-pdf
July 08, 2020 - Hidden in plain sight — reconsidering the use of race
correction in clinical algorithms.
July 8, 2020
Vyas DA, Eisenstein LG, Jones DS. Hidden in plain sight — reconsidering the use of race correction in
clinical algorithms. N Engl J Med. 2020;383(9):874-882. doi:10.1056/nejmms2004740.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/40861/psn-pdf
October 19, 2011 - Registered nurses' judgments of the classification and
risk level of patient care errors.
October 19, 2011
Chipps E, Wills CE, Tanda R, et al. Registered nurses' judgments of the classification and risk level of
patient care errors. J Nurs Care Qual. 2011;26(4):302-310. doi:10.1097/NCQ.0b013e31820f4c57.
https://ps…
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psnet.ahrq.gov/node/836870/psn-pdf
April 26, 2022 - A Conversation Among Stakeholders on Medical
Malpractice.
April 6, 2022
Collaborative for Accountability and Improvement. April 26, 2022.
https://psnet.ahrq.gov/issue/conversation-among-stakeholders-medical-malpractice
Communication and resolution programs (CRP) can improve response to patients and families a…
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psnet.ahrq.gov/node/851658/psn-pdf
July 26, 2023 - The spectrum of hospitalization-associated harm in the
elderly.
July 26, 2023
Schattner A. The spectrum of hospitalization-associated harm in the elderly. Eur J Intern Med.
2023;115(Sept):29-33. doi:10.1016/j.ejim.2023.05.025.
https://psnet.ahrq.gov/issue/spectrum-hospitalization-associated-harm-elderly
Older pat…
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psnet.ahrq.gov/node/45931/psn-pdf
July 05, 2017 - The CARE approach to reducing diagnostic errors.
July 5, 2017
Rush JL, Helms SE, Mostow EN. The CARE approach to reducing diagnostic errors. Int J Dermatol.
2017;56(6):669-673. doi:10.1111/ijd.13532.
https://psnet.ahrq.gov/issue/care-approach-reducing-diagnostic-errors
Cognitive aids such as checklists and mnemoni…
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psnet.ahrq.gov/node/37881/psn-pdf
July 02, 2008 - Simulated laparoscopic operating room crisis: an
approach to enhance the surgical team performance.
July 2, 2008
Powers KA, Rehrig ST, Irias N, et al. Simulated laparoscopic operating room crisis: An approach to
enhance the surgical team performance. Surg Endosc. 2008;22(4):885-900.
https://psnet.ahrq.gov/issue/si…
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psnet.ahrq.gov/node/34788/psn-pdf
March 28, 2005 - Cost of medication-related problems at a university
hospital.
March 28, 2005
Schneider PJ; Gift MG; Lee YP; Rothermich EA; Sill BE
https://psnet.ahrq.gov/issue/cost-medication-related-problems-university-hospital
This study used retrospective chart review to determine estimated costs of defined medication-related
…
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psnet.ahrq.gov/node/42057/psn-pdf
February 20, 2013 - Improving patient safety in the operating theatre and
perioperative care: obstacles, interventions, and priorities
for accelerating progress.
February 20, 2013
Sevdalis N, Hull L, Birnbach DJ. Improving patient safety in the operating theatre and perioperative care:
obstacles, interventions, and priorities for acc…
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psnet.ahrq.gov/node/36075/psn-pdf
September 28, 2010 - Sample to sample carryover: a source of analytical
laboratory error and its relevance to integrated clinical
chemistry/immunoassay systems.
September 28, 2010
Armbruster DA, Alexander DB. Sample to sample carryover: a source of analytical laboratory error and its
relevance to integrated clinical chemistry/immunoas…
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psnet.ahrq.gov/node/60727/psn-pdf
July 29, 2020 - A randomized trial of a multifactorial strategy to prevent
serious fall injuries.
July 29, 2020
Bhasin S, Gill TM, Reuben DB, et al. A randomized trial of a multifactorial strategy to prevent serious fall
injuries. N Engl J Med. 2020;383(2):129-140. doi:10.1056/nejmoa2002183.
https://psnet.ahrq.gov/issue/randomize…
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psnet.ahrq.gov/node/45169/psn-pdf
June 08, 2016 - High Reliability in Health Care.
June 8, 2016
Joint Commission Center for Transforming Healthcare.
https://psnet.ahrq.gov/issue/high-reliability-health-care
Development of high reliability remains an elusive goal for health care organizations. The Joint Commission
has also advocated for achieving high reliability …
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psnet.ahrq.gov/node/867531/psn-pdf
January 15, 2025 - Psychological Safety in Healthcare Settings.
January 15, 2025
Psychological Safety in Healthcare Settings. Int J Public Health. 2024;69.
https://psnet.ahrq.gov/issue/psychological-safety-healthcare-settings
The importance of creating healthcare environments that enable concerns to be voiced and support
individuals…
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psnet.ahrq.gov/node/42943/psn-pdf
April 12, 2014 - Doing right by our patients when things go wrong in the
ambulatory setting.
April 12, 2014
Schiff G, Griswold P, Ellis BR, et al. Doing right by our patients when things go wrong in the ambulatory
setting. Jt Comm J Qual Patient Saf. 2014;40(2):91-96.
https://psnet.ahrq.gov/issue/doing-right-our-patients-when-thin…