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psnet.ahrq.gov/node/74838/psn-pdf
February 16, 2022 - Overstating inpatient deaths due to medical error erodes
trust in healthcare and the patient safety movement.
February 16, 2022
Gunderson CG, Rodwin BA. Overstating inpatient deaths due to medical error erodes trust in healthcare
and the patient safety movement. J Hosp Med. 2022;17(5):399-402. doi:10.1002/jhm.2768.…
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psnet.ahrq.gov/node/72718/psn-pdf
February 10, 2021 - Assessing reasons for decreased primary care access for
individuals on prescribed opioids: an audit study.
February 10, 2021
Lagisetty P, Macleod C, Thomas J, et al. Assessing reasons for decreased primary care access for
individuals on prescribed opioids. Pain. 2021;162(5):1379-1386. doi:10.1097/j.pain.00000000000…
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psnet.ahrq.gov/node/34085/psn-pdf
February 09, 2011 - Discussion of medical errors in morbidity and mortality
conferences.
February 9, 2011
Pierluissi E, Fischer M, Campbell AR, et al. Discussion of medical errors in morbidity and mortality
conferences. JAMA. 2003;290(21):2838-2842.
https://psnet.ahrq.gov/issue/discussion-medical-errors-morbidity-and-mortality-confer…
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psnet.ahrq.gov/node/45299/psn-pdf
July 20, 2016 - Reducing readmission at an academic medical center:
results of a pharmacy-facilitated discharge counseling
and medication reconciliation program.
July 20, 2016
Zemaitis CT, Morris G, Cabie M, et al. Reducing Readmission at an Academic Medical Center: Results of a
Pharmacy-Facilitated Discharge Counseling and Medic…
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psnet.ahrq.gov/node/38491/psn-pdf
January 31, 2011 - Diagnostic errors--The next frontier for patient safety.
January 31, 2011
Newman-Toker DE, Pronovost P. Diagnostic errors--the next frontier for patient safety. JAMA.
2009;301(10):1060-2. doi:10.1001/jama.2009.249.
https://psnet.ahrq.gov/issue/diagnostic-errors-next-frontier-patient-safety
Studies from autopsy dat…
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psnet.ahrq.gov/node/36797/psn-pdf
August 26, 2011 - The American College of Surgeons' closed claims study:
new insights for improving care.
August 26, 2011
Griffen FD, Stephens LS, Alexander JB, et al. The American College of Surgeons’ Closed Claims Study:
New Insights for Improving Care. J Am Coll Surg. 2007;204(4). doi:10.1016/j.jamcollsurg.2007.01.013.
https://p…
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psnet.ahrq.gov/node/848820/psn-pdf
May 10, 2023 - Error disclosure in neonatal intensive care: a multicentre,
prospective, observational study.
May 10, 2023
Passini L, Le Bouedec S, Dassieu G, et al. Error disclosure in neonatal intensive care: a multicentre,
prospective, observational study. BMJ Qual Saf. 2023;32(10):589-599. doi:10.1136/bmjqs-2022-015247.
https…
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psnet.ahrq.gov/node/837632/psn-pdf
July 06, 2022 - Serious experience events: applying patient safety
concepts to improve patient experience.
July 6, 2022
Donnelly LF, Uhlhorn E, Bargmann-Losche J, et al. Serious experience events: applying patient safety
concepts to improve patient experience. J Patient Exp. 2022;9:237437352211026.
doi:10.1177/23743735221102670.
…
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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/35802/psn-pdf
January 02, 2017 - Reconciliation failures lead to medication errors.
January 2, 2017
Santell JP. Reconciliation failures lead to medication errors. Jt Comm J Qual Patient Saf. 2006;32(4):225-9.
https://psnet.ahrq.gov/issue/reconciliation-failures-lead-medication-errors
Medication reconciliation represents an active effort of hospita…
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psnet.ahrq.gov/node/866313/psn-pdf
July 17, 2024 - Towards understanding and improving medication safety
for patients with mental illness in primary care: a
multimethod study.
July 17, 2024
Ayre MJ, Lewis PJ, Phipps DL, et al. Towards understanding and improving medication safety for patients
with mental illness in primary care: a multimethod study. Health Expect.…
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psnet.ahrq.gov/node/72707/psn-pdf
February 03, 2021 - Identification and safe storage of look-alike, sound-alike
medicines in automated dispensing cabinets.
February 3, 2021
Ruutiainen HK, Kallio MM, Kuitunen SK. Identification and safe storage of look-alike, sound-alike medicines
in automated dispensing cabinets. Eur J Hosp Pharm. 2021;28(Suppl 2):e151-e156. doi:10.1…
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psnet.ahrq.gov/node/836807/psn-pdf
March 30, 2022 - Preventing delayed and missed care by applying artificial
intelligence to trigger radiology imaging follow-up.
March 30, 2022
Domingo J, Galal G, Huang J. Preventing delayed and missed care by applying artificial intelligence to
trigger radiology imaging follow-up. NEJM Catal Innov Care Deliv. 2022;3(4).
https://p…
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psnet.ahrq.gov/node/35403/psn-pdf
February 18, 2011 - Mortality among patients admitted to hospitals on
weekends as compared with weekdays.
February 18, 2011
Bell CM, Redelmeier DA. Mortality among patients admitted to hospitals on weekends as compared with
weekdays. New Engl J Med. 2001;345(9):663-668.
https://psnet.ahrq.gov/issue/mortality-among-patients-admitted-h…
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psnet.ahrq.gov/node/46423/psn-pdf
December 16, 2017 - Ethical considerations on disclosure when medical error
is discovered during medicolegal death investigation.
December 16, 2017
Wolf DA, Drake SA, Snow FK. Ethical Considerations on Disclosure When Medical Error Is Discovered
During Medicolegal Death Investigation. Am J Forensic Med Pathol. 2017;38(4):294-297.
doi…
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psnet.ahrq.gov/node/73637/psn-pdf
August 25, 2021 - Failures in Care Coordination and Reviewing a Patient's
Death at the VA Salt Lake City Healthcare System in Utah.
August 25, 2021
Washington, DC: Department of Veterans Affairs, Office of Inspector General. July 29, 2021. Report
No. 21-00657-197.
https://psnet.ahrq.gov/issue/failures-care-coordination-and-re…
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psnet.ahrq.gov/node/839826/psn-pdf
November 09, 2022 - Professional behavior and value erosion: a qualitative
study of physicians and the electronic health record.
November 9, 2022
Skeff KM, Brown-Johnson CG, Asch SM, et al. Professional behavior and value erosion: a qualitative study
of physicians and the electronic health record. J Healthc Manag. 2022;67(5):339-352. …
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psnet.ahrq.gov/node/861763/psn-pdf
January 31, 2024 - The process and perspective of serious incident
investigations in adult community mental health services:
integrative review and synthesis.
January 31, 2024
Haylor H, Sparkes T, Armitage G, et al. The process and perspective of serious incident investigations in
adult community mental health services: integrative …
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psnet.ahrq.gov/node/38662/psn-pdf
April 12, 2011 - Patient error: a preliminary taxonomy.
April 12, 2011
Buetow S, Kiata L, Liew T, et al. Patient error: a preliminary taxonomy. Ann Fam Med. 2009;7(3):223-31.
doi:10.1370/afm.941.
https://psnet.ahrq.gov/issue/patient-error-preliminary-taxonomy
Preliminary research has found that patient factors may contribute to er…
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psnet.ahrq.gov/node/866518/psn-pdf
January 01, 2025 - Hospital rating organizations' quality and patient safety
scores: analysis of result discrepancies.
August 14, 2024
Badr S, Nahle T, Rahman S, et al. Hospital rating organizations' quality and patient safety scores: analysis
of result discrepancies. J Gen Intern Med. 2025;40(3):525-531. doi:10.1007/s11606-024-08950…