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psnet.ahrq.gov/node/43543/psn-pdf
November 05, 2014 - A patient safety approach to setting pass/fail standards
for basic procedural skills checklists.
November 5, 2014
Yudkowsky R, Tumuluru S, Casey P, et al. A patient safety approach to setting pass/fail standards for basic
procedural skills checklists. Simul Healthc. 2014;9(5):277-82. doi:10.1097/SIH.000000000000004…
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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/45335/psn-pdf
August 10, 2016 - The Feasibility of Determining the Effectiveness and Cost-
effectiveness of Medication Organisation Devices
Compared with Usual Care for Older People in a
Community Setting: Systematic Review, Stakeholder
Focus Groups and Feasibility RCT.
August 10, 2016
Bhattacharya D, Aldus CF, Barton G, et al. Health Tech…
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psnet.ahrq.gov/node/45973/psn-pdf
March 29, 2017 - Clinical perspective: creating an effective practice peer
review process—a primer.
March 29, 2017
Gandhi M, Louis FS, Wilson SH, et al. Clinical perspective: creating an effective practice peer review
process-a primer. Am J Obstet Gynecol. 2017;216(3):244-249. doi:10.1016/j.ajog.2016.11.1035.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/42400/psn-pdf
July 10, 2013 - Development and reliability of the explicit professional
oral communication observation tool to quantify the use
of non-technical skills in healthcare.
July 10, 2013
Kemper PF, van Noord I, de Bruijne M, et al. Development and reliability of the explicit professional oral
communication observation tool to quantify…
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psnet.ahrq.gov/node/73652/psn-pdf
September 01, 2021 - Dimensions of safety culture: a systematic review of
quantitative, qualitative and mixed methods for assessing
safety culture in hospitals.
September 1, 2021
Churruca K, Ellis LA, Pomare C, et al. Dimensions of safety culture: a systematic review of quantitative,
qualitative and mixed methods for assessing safety …
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psnet.ahrq.gov/node/46351/psn-pdf
December 19, 2017 - Intraoperative surgical performance measurement and
outcomes: choose your tools carefully.
December 19, 2017
Aggarwal R. Intraoperative Surgical Performance Measurement and Outcomes: Choose Your Tools
Carefully. JAMA Surg. 2017;152(11):995-996. doi:10.1001/jamasurg.2017.0837.
https://psnet.ahrq.gov/issue/intraoper…
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psnet.ahrq.gov/node/60301/psn-pdf
January 01, 2021 - Association of surgical resident wellness with medical
errors and patient outcomes.
May 6, 2020
Hewitt DB, Ellis RJ, Chung JW, et al. Association of surgical resident wellness with medical errors and
patient outcomes. Ann Surg. 2021;274(2):396-402. doi:10.1097/sla.0000000000003909.
https://psnet.ahrq.gov/issue/ass…
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psnet.ahrq.gov/node/74701/psn-pdf
January 26, 2022 - Non-conveyance of older adult patients and association
with subsequent clinical and adverse events after initial
assessment by ambulance clinicians: a cohort analysis.
January 26, 2022
Lederman J, Lindström V, Elmqvist C, et al. Non-conveyance of older adult patients and association with
subsequent clinical and ad…
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psnet.ahrq.gov/node/47523/psn-pdf
December 05, 2018 - Developing standardized "receiver-driven" handoffs
between referring providers and the emergency
department: results of a multidisciplinary needs
assessment.
December 5, 2018
Huth K, Stack AM, Chi G, et al. Developing Standardized "Receiver-Driven" Handoffs Between Referring
Providers and the Emergency Department…
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psnet.ahrq.gov/node/45576/psn-pdf
July 02, 2017 - Peer feedback, learning, and improvement: answering the
call of the Institute of Medicine report on diagnostic error.
July 2, 2017
Larson DB, Donnelly LF, Podberesky DJ, et al. Peer Feedback, Learning, and Improvement: Answering the
Call of the Institute of Medicine Report on Diagnostic Error. Radiology. 2017;283(1…
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psnet.ahrq.gov/node/837764/psn-pdf
August 03, 2022 - Disparities in adverse event reporting for hospitalized
children.
August 3, 2022
Halvorson EE, Thurtle DP, Easter A, et al. Disparities in adverse event reporting for hospitalized children. J
Patient Saf. 2022;18(6):e928-e933. doi:10.1097/pts.0000000000001049.
https://psnet.ahrq.gov/issue/disparities-adverse-event…
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psnet.ahrq.gov/node/859340/psn-pdf
December 20, 2023 - Validation and use of the Second Victim Experience and
Support Tool questionnaire: a scoping review.
December 20, 2023
Dato Md Yusof YJ, Ng QX, Teoh SE, et al. Validation and use of the Second Victim Experience and
Support Tool questionnaire: a scoping review. Public Health. 2023;223:183-192.
doi:10.1016/j.puhe.20…
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psnet.ahrq.gov/node/42932/psn-pdf
December 30, 2014 - SBAR improves communication and safety climate and
decreases incident reports due to communication errors
in an anaesthetic clinic: a prospective intervention study.
December 30, 2014
Randmaa M, Mårtensson G, Swenne CL, et al. SBAR improves communication and safety climate and
decreases incident reports due to com…
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psnet.ahrq.gov/node/49704/psn-pdf
March 01, 2014 - Late Anemia Following Rh Disease in a Newborn
March 1, 2014
Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
The Case
A full-term neonate was delivered uneventfully to an Rh-negative woman who had re…
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psnet.ahrq.gov/web-mm/not-miscarriage
June 01, 2005 - Not a Miscarriage
Citation Text:
Learman LA. Not a Miscarriage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/issue/new-tool-give-hospitalists-feedback-improve-interprofessional-teamwork-and-advance-patient
February 10, 2015 - Commentary
A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care.
Citation Text:
Chesluk BJ, Bernabeo E, Hess B, et al. A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care. Health Aff…
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psnet.ahrq.gov/issue/diagnostic-stewardship-prevent-diagnostic-error
May 05, 2021 - Commentary
Diagnostic stewardship to prevent diagnostic error.
Citation Text:
Morgan DJ, Malani PN, Diekema DJ. Diagnostic stewardship to prevent diagnostic error. JAMA. 2023;329(15):1255-1256. doi:10.1001/jama.2023.1678.
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psnet.ahrq.gov/issue/enhancing-medication-use-safety-benefits-learning-your-peers
May 07, 2008 - Study
Enhancing medication use safety: benefits of learning from your peers.
Citation Text:
Kazandjian VA, Ogunbo S, Wicker KG, et al. Enhancing medication use safety: benefits of learning from your peers. Qual Saf Health Care. 2009;18(5):331-5. doi:10.1136/qshc.2008.027938.
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psnet.ahrq.gov/issue/supervision-autonomy-and-medical-error-teaching-clinic
November 26, 2014 - Commentary
Supervision, autonomy, and medical error in the teaching clinic.
Citation Text:
Cossman JP, Wang M, Fischer AA. Supervision, autonomy, and medical error in the teaching clinic. J Am Acad Dermatol. 2018;79(5):981-983. doi:10.1016/j.jaad.2017.12.033.
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