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psnet.ahrq.gov/node/837973/psn-pdf
August 31, 2022 - Acute clinical deterioration and consumer escalation: the
understanding and perceptions of hospital staff.
August 31, 2022
Thiele L, Flabouris A, Thompson C. Acute clinical deterioration and consumer escalation: the
understanding and perceptions of hospital staff. PLoS ONE. 2022;17(6):e0269921.
doi:10.1371/journal…
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psnet.ahrq.gov/node/35374/psn-pdf
January 02, 2017 - Intimidation: practitioners speak up about this unresolved
problem.
January 2, 2017
Smetzer JL, Cohen MR. Intimidation: Practitioners Speak Up About This Unresolved Problem. Jt Comm J
Qual Patient Saf. 2016;31(10):594-599. doi:10.1016/s1553-7250(05)31077-4.
https://psnet.ahrq.gov/issue/intimidation-practitioners-s…
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psnet.ahrq.gov/node/44736/psn-pdf
December 16, 2015 - Harms from discharge to primary care: mixed methods
analysis of incident reports.
December 16, 2015
Williams H, Edwards A, Hibbert P, et al. Harms from discharge to primary care: mixed methods analysis of
incident reports. Br J Gen Pract. 2015;65(641):e829-e837. doi:10.3399/bjgp15X687877.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/74858/psn-pdf
February 23, 2022 - Improving responses to safety incidents: we need to talk
about justice.
February 23, 2022
Cribb A, O'Hara JK, Waring J. Improving responses to safety incidents: we need to talk about justice. BMJ
Qual Saf. 2022;31(4):327-330. doi:10.1136/bmjqs-2021-014333.
https://psnet.ahrq.gov/issue/improving-responses-safety-in…
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psnet.ahrq.gov/node/838623/psn-pdf
October 19, 2022 - Resident and nurse perspectives on the use of secure
text messaging systems.
October 19, 2022
Aziz S, Barber J, Singh A, et al. Resident and nurse perspectives on the use of secure text messaging
systems. J Hosp Med. 2022;17(11):880-887. doi:10.1002/jhm.12953.
https://psnet.ahrq.gov/issue/resident-and-nurse-perspe…
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psnet.ahrq.gov/node/40177/psn-pdf
June 08, 2011 - Learning from disasters to improve patient safety:
applying the generic disaster pathway to health system
errors.
June 8, 2011
Travaglia J, Hughes C, Braithwaite J. Learning from disasters to improve patient safety: applying the
generic disaster pathway to health system errors. BMJ Qual Saf. 2011;20(1):1-8.
doi:1…
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psnet.ahrq.gov/node/43485/psn-pdf
December 15, 2014 - Implementation of an emergency department sign-out
checklist improves transfer of information at shift change.
December 15, 2014
Dubosh NM, Carney D, Fisher J, et al. Implementation of an emergency department sign-out checklist
improves transfer of information at shift change. J Emerg Med. 2014;47(5):580-5.
doi:10…
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psnet.ahrq.gov/node/865974/psn-pdf
May 29, 2024 - Minimizing bias when using artificial intelligence in
critical care medicine.
May 29, 2024
Ranard BL, Park S, Jia Y, et al. Minimizing bias when using artificial intelligence in critical care medicine. J
Crit Care. 2024;82:154796. doi:10.1016/j.jcrc.2024.154796.
https://psnet.ahrq.gov/issue/minimizing-bias-when-us…
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psnet.ahrq.gov/node/39614/psn-pdf
June 18, 2021 - Preventing violence in the health care setting.
June 18, 2021
Preventing violence in the health care setting. Sentinel Event Alert. 2010;(45):1-3.
https://psnet.ahrq.gov/issue/preventing-violence-health-care-setting
Revised June 2021. The Joint Commission issues sentinel event alerts to highlight areas of high risk…
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psnet.ahrq.gov/node/853233/psn-pdf
September 06, 2023 - Weight estimation for drug dose calculations in the
prehospital setting - a systematic review.
September 6, 2023
Wells M, Henry B, Goldstein L. Weight estimation for drug dose calculations in the prehospital setting - a
systematic review. Prehosp Disaster Med. 2023;38(4):471-484. doi:10.1017/s1049023x23006027.
htt…
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psnet.ahrq.gov/node/47456/psn-pdf
April 30, 2019 - ISMP Gap Analysis Tool (GAT) for Safe IV Push
Medication Practices.
April 30, 2019
Horsham, PA: Institute for Safe Medication Practices; 2018.
https://psnet.ahrq.gov/issue/ismp-gap-analysis-tool-gat-safe-iv-push-medication-practices
Standardized practices have not been uniformly adopted to support safe IV medicati…
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psnet.ahrq.gov/node/46479/psn-pdf
October 04, 2017 - Managing the Costs of Clinical Negligence in Trusts.
October 4, 2017
Comptroller and Auditor General, Department of Health; London, UK: National Audit Office; 2017. ISBN:
9781786041395.
https://psnet.ahrq.gov/issue/managing-costs-clinical-negligence-trusts
Applying evidence generated from complaints submitted to h…
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psnet.ahrq.gov/node/44170/psn-pdf
May 29, 2023 - Ambulatory Surgery Center Survey on Patient Safety
Culture.
May 29, 2023
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
https://psnet.ahrq.gov/issue/ambulatory-surgery-center-survey-patient-safety-culture
Ambulatory surgery centers (ASCs) are increasingly being used to provide surgical ca…
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psnet.ahrq.gov/node/73077/psn-pdf
March 24, 2021 - Well-Being Playbook 2.0. A COVID-19 Resource for
Hospital and Health System Leaders.
March 24, 2021
AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.
https://psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders
Human factors enginee…
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psnet.ahrq.gov/node/44330/psn-pdf
September 02, 2015 - Health Literacy: Past, Present, and Future: Workshop
Summary.
September 2, 2015
Alper J; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of
Medicine. Washington, DC: National Academies of Sciences, Engineering, and Medicine; 2015. ISBN:
9780309371544.
https://psnet.…
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psnet.ahrq.gov/node/45028/psn-pdf
May 25, 2016 - 'Just culture': improving safety by achieving substantive,
procedural and restorative justice.
May 25, 2016
Dekker SWA, Breakey H. ‘Just culture:’ Improving safety by achieving substantive, procedural and
restorative justice. Saf Sci. 2016;85. doi:10.1016/j.ssci.2016.01.018.
https://psnet.ahrq.gov/issue/just-cultu…
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psnet.ahrq.gov/node/39840/psn-pdf
September 15, 2010 - Wrong-site craniotomy: analysis of 35 cases and systems
for prevention.
September 15, 2010
Cohen FL, Mendelsohn D, Bernstein M. Wrong-site craniotomy: analysis of 35 cases and systems for
prevention. J Neurosurg. 2010;113(3):461-73. doi:10.3171/2009.10.JNS091282.
https://psnet.ahrq.gov/issue/wrong-site-craniotomy-…
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psnet.ahrq.gov/node/45035/psn-pdf
January 23, 2017 - Premature closure? Not so fast.
January 23, 2017
Dhaliwal G. Premature closure? Not so fast. BMJ Qual Saf. 2017;26(2):87-89. doi:10.1136/bmjqs-2016-
005267.
https://psnet.ahrq.gov/issue/premature-closure-not-so-fast
Analyzing clinician decision making is increasingly suggested as a strategy to reduce diagnostic er…
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psnet.ahrq.gov/node/39356/psn-pdf
April 08, 2011 - Team training in the neonatal resuscitation program for
interns: teamwork and quality of resuscitations.
April 8, 2011
Thomas EJ, Williams AL, Reichman EF, et al. Team training in the neonatal resuscitation program for
interns: teamwork and quality of resuscitations. Pediatrics. 2010;125(3):539-546. doi:10.1542/ped…
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psnet.ahrq.gov/node/48028/psn-pdf
August 28, 2019 - Error Reduction and Prevention in Surgical Pathology,
Second Edition.
August 28, 2019
Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.
https://psnet.ahrq.gov/issue/error-reduction-and-prevention-surgical-pathology-2nd-edition
Surgical specimen and laboratory process proble…