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psnet.ahrq.gov/node/44479/psn-pdf
September 09, 2015 - Health literacy in primary care practice.
September 9, 2015
Hersh L, Salzman B, Snyderman D. Health Literacy in Primary Care Practice. Am Fam Physician.
2015;92(2):118-124.
https://psnet.ahrq.gov/issue/health-literacy-primary-care-practice
Limited health literacy can lead to patients misunderstanding care instruct…
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psnet.ahrq.gov/node/73429/psn-pdf
June 23, 2021 - Wrong Site Surgery - Wrong Patient: Invasive Procedures
in Outpatient Settings.
June 23, 2021
Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.
https://psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
Wrong site/wrong patent surgery is a persisten…
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psnet.ahrq.gov/node/45270/psn-pdf
June 29, 2016 - Using contemporary leadership skills in medication safety
programs.
June 29, 2016
Hertig JB, Hultgren KE, Weber RJ. Using Contemporary Leadership Skills in Medication Safety Programs.
Hosp Pharm. 2016;51(4):338-44. doi:10.1310/hpj5104-338.
https://psnet.ahrq.gov/issue/using-contemporary-leadership-skills-medicatio…
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psnet.ahrq.gov/node/44161/psn-pdf
December 19, 2018 - Among the elderly, many mental illnesses go
undiagnosed.
December 19, 2018
Bor JS. Among the elderly, many mental illnesses go undiagnosed. Health Aff (Millwood). 2015;34(5):727-
31. doi:10.1377/hlthaff.2015.0314.
https://psnet.ahrq.gov/issue/among-elderly-many-mental-illnesses-go-undiagnosed
This commentary spot…
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psnet.ahrq.gov/node/42881/psn-pdf
January 22, 2014 - Speaking up about the dangers of the hidden curriculum.
January 22, 2014
Liao JM, Thomas EJ, Bell SK. Speaking up about the dangers of the hidden curriculum. Health Aff
(Millwood). 2014;33(1):168-171. doi:10.1377/hlthaff.2013.1073.
https://psnet.ahrq.gov/issue/speaking-about-dangers-hidden-curriculum
Relating an a…
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psnet.ahrq.gov/node/45015/psn-pdf
July 18, 2016 - Interhospital transfer handoff practices among US tertiary
care centers: a descriptive survey.
July 18, 2016
Herrigel DJ, Carroll M, Fanning C, et al. Interhospital transfer handoff practices among US tertiary care
centers: A descriptive survey. J Hosp Med. 2016;11(6):413-7. doi:10.1002/jhm.2577.
https://psnet.ahr…
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psnet.ahrq.gov/node/42272/psn-pdf
November 26, 2014 - Effect of a systems intervention on the quality and safety
of patient handoffs in an internal medicine residency
program.
November 26, 2014
Graham KL, Marcantonio ER, Huang GC, et al. Effect of a systems intervention on the quality and safety of
patient handoffs in an internal medicine residency program. J Gen Int…
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psnet.ahrq.gov/node/60819/psn-pdf
August 19, 2020 - Register-based research of adverse events revealing
incomplete records threatening patient safety.
August 19, 2020
Kinnunen U-M, Kivekäs E, Palojoki S, et al. Register-based research of adverse events revealing
incomplete records threatening patient safety. Stud Health Technol Inform. 2020;270:771-775.
doi:10.3233…
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psnet.ahrq.gov/node/42931/psn-pdf
April 20, 2014 - Assigning a team-based pager for on-call physicians
reduces paging errors in a large academic hospital.
April 20, 2014
Shieh L, Chi J, Kulik C, et al. Assigning a team-based pager for on-call physicians reduces paging errors in
a large academic hospital. Jt Comm J Qual Patient Saf. 2014;40(2):77-82.
https://psnet.…
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psnet.ahrq.gov/node/41459/psn-pdf
August 02, 2012 - The use of simulation in healthcare: from systems issues,
to team building, to task training, to education and high
stakes examinations.
August 2, 2012
Orledge J, Phillips WJ, Murray B, et al. The use of simulation in healthcare: from systems issues, to team
building, to task training, to education and high stakes…
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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/838030/psn-pdf
September 07, 2022 - Rethinking use of air-safety principles to reduce fatal
hospital errors.
September 7, 2022
Rethinking use of air-safety principles to reduce fatal hospital errors.
doi:10.1377/forefront.20220824.965364.
https://psnet.ahrq.gov/issue/rethinking-use-air-safety-principles-reduce-fatal-hospital-errors
The safety of co…
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psnet.ahrq.gov/node/50561/psn-pdf
October 16, 2019 - Patient Safety Organizations: Hospital Participation,
Value, and Challenges.
October 16, 2019
US Department of Health and Human Services; Office of the Inspector General, September 2019. OIG
Report No. OEI-01-17-00420.
https://psnet.ahrq.gov/issue/patient-safety-organizations-hospital-participation-value-and…
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psnet.ahrq.gov/node/837626/psn-pdf
July 06, 2022 - Frailty, gaps in care coordination, and preventable
adverse events.
July 6, 2022
Akinyelure OP, Colvin CL, Sterling MR, et al. Frailty, gaps in care coordination, and preventable adverse
events. BMC Geriatr. 2022;22(1):476. doi:10.1186/s12877-022-03164-7.
https://psnet.ahrq.gov/issue/frailty-gaps-care-coordination…
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psnet.ahrq.gov/node/47060/psn-pdf
April 25, 2018 - Patient safety vulnerabilities for children with intellectual
disability in hospital: a systematic review and narrative
synthesis.
April 25, 2018
Mimmo L, Harrison R, Hinchcliff R. Patient safety vulnerabilities for children with intellectual disability in
hospital: a systematic review and narrative synthesis. BMJ…
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psnet.ahrq.gov/node/46699/psn-pdf
March 20, 2018 - Disclosure of harmful medical error to patients: a review
with recommendations for pathologists.
March 20, 2018
Heher YK, Dintzis SM. Disclosure of Harmful Medical Error to Patients: A Review With Recommendations
for Pathologists. Adv Anat Pathol. 2018;25(2):124-130. doi:10.1097/PAP.0000000000000181.
https://psnet…
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psnet.ahrq.gov/node/46716/psn-pdf
January 10, 2018 - Toolkit to Engage High-Risk Patients in Safe Transitions
Across Ambulatory Settings.
January 10, 2018
Davis K, Collier S, Situ J, et al. Rockville, MD: Agency for Healthcare Research and Quality; December
2017. AHRQ Publication No. 1800051EF.
https://psnet.ahrq.gov/issue/toolkit-engage-high-risk-patients-safe-tran…
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psnet.ahrq.gov/node/859347/psn-pdf
December 20, 2023 - Making surgery as safe as it should be: a qualitative
study.
December 20, 2023
Robinson DJ, Beaumont G. Making surgery as safe as it should be: a qualitative study. Am J Med Qual.
2023;38(5):238-244. doi:10.1097/jmq.0000000000000139.
https://psnet.ahrq.gov/issue/making-surgery-safe-it-should-be-qualitative-study
…
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psnet.ahrq.gov/node/46973/psn-pdf
June 25, 2018 - Balancing innovation and safety when integrating digital
tools into health care.
June 25, 2018
Auerbach AD, Neinstein A, Khanna R. Balancing Innovation and Safety When Integrating Digital Tools Into
Health Care. Ann Intern Med. 2018;168(10):733-734. doi:10.7326/M17-3108.
https://psnet.ahrq.gov/issue/balancing-inno…
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psnet.ahrq.gov/node/837140/psn-pdf
May 18, 2022 - Nursing surveillance: a concept analysis
May 18, 2022
Halverson CC, Scott Tilley D. Nursing surveillance: a concept analysis. Nurs Forum. 2022;57(3):454-460.
doi:10.1111/nuf.12702.
https://psnet.ahrq.gov/issue/nursing-surveillance-concept-analysis
Nursing surveillance is an intervention for maintaining patient saf…