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psnet.ahrq.gov/node/38923/psn-pdf
September 09, 2009 - Improving communication in the emergency department.
September 9, 2009
Redfern E, Brown R, Vincent C. Improving communication in the emergency department. Emerg Med J.
2009;26(9):658-61. doi:10.1136/emj.2008.065623.
https://psnet.ahrq.gov/issue/improving-communication-emergency-department
Implementation of structu…
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psnet.ahrq.gov/node/41492/psn-pdf
June 27, 2018 - Alarm fatigue hazards: the sirens are calling.
June 27, 2018
Welch J.
https://psnet.ahrq.gov/issue/alarm-fatigue-hazards-sirens-are-calling
This article reports on alarm fatigue in clinical care, including the risks associated with it, and describes
tactics to help reduce nuisance alarms.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/37016/psn-pdf
September 15, 2011 - Postoperative complications due to a retained surgical
sponge.
September 15, 2011
Sarda AK, Pandey D, Neogi S, et al. Postoperative complications due to a retained surgical sponge.
Singapore Med J. 2007;48(6):e160-4.
https://psnet.ahrq.gov/issue/postoperative-complications-due-retained-surgical-sponge
The authors…
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psnet.ahrq.gov/node/36953/psn-pdf
June 13, 2007 - Quality and Safety Education for Nurses.
June 13, 2007
Cronenwett L, ed. Nurs Outlook. 2007;55(3):117-162.
https://psnet.ahrq.gov/issue/quality-and-safety-education-nurses
This issue covers a variety of topics related to quality and safety education for nurses, including the
integration of safety content into dail…
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psnet.ahrq.gov/node/42508/psn-pdf
December 18, 2017 - Watson: Beyond Jeopardy!
December 18, 2017
Ferrucci D, Levas A, Bagchi S, et al. Watson: Beyond Jeopardy!. Artif Intell. 2012;199-200.
doi:10.1016/j.artint.2012.06.009.
https://psnet.ahrq.gov/issue/watson-beyond-jeopardy
This commentary describes how question answering systems can augment evidence-based decision
…
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psnet.ahrq.gov/node/41736/psn-pdf
September 02, 2016 - Drug shortages and clinicians: no time for complacency.
September 2, 2016
Rochon P, Gurwitz JH. Drug shortages and clinicians: no time for complacency. Arch Intern Med.
2012;172(19):1499-500.
https://psnet.ahrq.gov/issue/drug-shortages-and-clinicians-no-time-complacency
This article comments on the patient safety …
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psnet.ahrq.gov/node/35333/psn-pdf
July 14, 2009 - Medication errors and drug-dispensing systems in a
hospital pharmacy.
July 14, 2009
Anacleto TA, Perini E, Rosa MB, et al. Medication errors and drug-dispensing systems in a hospital
pharmacy. Clinics. 2006;60(4). doi:10.1590/s1807-59322005000400011.
https://psnet.ahrq.gov/issue/medication-errors-and-drug-dispensi…
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psnet.ahrq.gov/node/39159/psn-pdf
May 04, 2010 - Radiologists' responses to inadequate referrals.
May 4, 2010
Lysdahl KB, Hofmann BM, Espeland A. Radiologists' responses to inadequate referrals. Eur Radiol.
2010;20(5):1227-33. doi:10.1007/s00330-009-1640-y.
https://psnet.ahrq.gov/issue/radiologists-responses-inadequate-referrals
Radiologists frequently receive i…
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psnet.ahrq.gov/issue/massive-open-online-course-mooc-learning-builds-capacity-and-improves-competence-patient
October 14, 2020 - Study
Massive open online course (MOOC) learning builds capacity and improves competence for patient safety among global learners: a prospective cohort study.
Citation Text:
Gleason KT, Commodore-Mensah Y, Wu AW, et al. Massive open online course (MOOC) learning builds capacity and impro…
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psnet.ahrq.gov/issue/diagnostic-uncertainty-among-critically-ill-children-admitted-picu-multicenter-study
June 14, 2023 - Study
Diagnostic uncertainty among critically ill children admitted to the PICU: a multicenter study.
Citation Text:
Cifra CL, Custer JW, Smith CM, et al. Diagnostic uncertainty among critically ill children admitted to the PICU: a multicenter study. Crit Care Med. 2025;53(2):e294-e307. …
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psnet.ahrq.gov/issue/burden-and-risk-factors-adverse-drug-events-older-patients-prospective-cross-sectional-study
May 20, 2020 - Study
The burden and risk factors for adverse drug events in older patients--a prospective cross-sectional study.
Citation Text:
Tipping B, Kalula S, Badri M. The burden and risk factors for adverse drug events in older patients--a prospective cross-sectional study. S Afr Med J. 2006;9…
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psnet.ahrq.gov/issue/implementing-robust-process-improvement-program-neonatal-intensive-care-unit-reduce-harm
March 23, 2022 - Study
Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm.
Citation Text:
Nether KG, Thomas EJ, Khan A, et al. Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. J Healthc Qual. 2022;44(1)…
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psnet.ahrq.gov/issue/transforming-medication-regimen-review-process-using-telemedicine-prevent-adverse-events
November 11, 2015 - Study
Transforming the medication regimen review process using telemedicine to prevent adverse events.
Citation Text:
Kane‐Gill SL, Wong A, Culley CM, et al. Transforming the medication regimen review process using telemedicine to prevent adverse events. J Am Geriatr Soc. 2020;69(2):530-…
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psnet.ahrq.gov/issue/cluster-randomized-trial-two-implementation-strategies-deliver-audit-and-feedback-equipped
September 01, 2018 - Study
A cluster randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program.
Citation Text:
Vaughan CP, Burningham Z, Kelleher JL, et al. A cluster‐randomized trial of two implementation strategies to deliver audit and feedbac…
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psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys
January 17, 2012 - Study
Classic
Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system.
Citation Text:
DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the V…
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psnet.ahrq.gov/issue/discrepancy-between-emergency-department-admission-diagnosis-and-hospital-discharge-diagnosis
December 08, 2021 - Study
Discrepancy between emergency department admission diagnosis and hospital discharge diagnosis and its impact on length of stay, up-triage to the intensive care unit, and mortality.
Citation Text:
Bastakoti M, Muhailan M, Nassar A, et al. Discrepancy between emergency department adm…
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psnet.ahrq.gov/issue/new-recommendations-duty-hours-acgme-task-force
July 14, 2021 - Commentary
Classic
The new recommendations on duty hours from the ACGME Task Force.
Citation Text:
Nasca TJ, Day SH, Amis S, et al. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3. doi:10.1056/NEJMsb1005800.
Copy…
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psnet.ahrq.gov/issue/failure-follow-test-results-ambulatory-patients-systematic-review
March 23, 2012 - Review
Classic
Failure to follow-up test results for ambulatory patients: a systematic review.
Citation Text:
Callen JL, Westbrook JI, Georgiou A, et al. Failure to Follow-Up Test Results for Ambulatory Patients: A Systematic Review. J Gen Intern Med. 2011;27(10…
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psnet.ahrq.gov/issue/psychological-impact-and-recovery-after-involvement-patient-safety-incident-repeated-measures
September 19, 2016 - Study
Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis.
Citation Text:
Van Gerven E, Bruyneel L, Panella M, et al. Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis.…
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psnet.ahrq.gov/issue/outcomes-associated-nationwide-introduction-rapid-response-systems-netherlands
January 18, 2013 - Study
Outcomes associated with the nationwide introduction of rapid response systems in the Netherlands.
Citation Text:
Ludikhuize J, Brunsveld-Reinders AH, Dijkgraaf MGW, et al. Outcomes Associated With the Nationwide Introduction of Rapid Response Systems in The Netherlands. Crit Care …