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psnet.ahrq.gov/node/46354/psn-pdf
November 21, 2017 - Controlled trial to improve resident sign-out in a medical
intensive care unit.
November 21, 2017
Nanchal R, Aebly B, Graves G, et al. Controlled trial to improve resident sign-out in a medical intensive
care unit. BMJ Qual Saf. 2017;26(12):987-992. doi:10.1136/bmjqs-2017-006657.
https://psnet.ahrq.gov/issue/contr…
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psnet.ahrq.gov/node/47685/psn-pdf
January 16, 2019 - Scaffolding our systems? Patients and families 'reaching
in' as a source of healthcare resilience.
January 16, 2019
O'Hara JK, Aase K, Waring J. Scaffolding our systems? Patients and families 'reaching in' as a source of
healthcare resilience. BMJ Qual Saf. 2019;28(1):3-6. doi:10.1136/bmjqs-2018-008216.
https://ps…
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psnet.ahrq.gov/node/45228/psn-pdf
June 29, 2016 - An innovative approach to the surgical time out: a patient-
focused model.
June 29, 2016
Kozusko SD, Elkwood L, Gaynor D, et al. An Innovative Approach to the Surgical Time Out: A Patient-
Focused Model. AORN J. 2016;103(6):617-22. doi:10.1016/j.aorn.2016.04.001.
https://psnet.ahrq.gov/issue/innovative-approach-su…
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psnet.ahrq.gov/node/35265/psn-pdf
February 03, 2011 - A 38-year-old woman with fetal loss and hysterectomy.
February 3, 2011
Sachs BP. A 38-Year-Old Woman With Fetal Loss and Hysterectomy. JAMA. 2005;294(7):833-840.
doi:10.1001/jama.294.7.833.
https://psnet.ahrq.gov/issue/38-year-old-woman-fetal-loss-and-hysterectomy
Part of a series in JAMA entitled Clinical Crossro…
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psnet.ahrq.gov/node/73589/psn-pdf
August 11, 2021 - Suicide and suicide attempts on hospital grounds and
clinic areas.
August 11, 2021
Mills PD, Watts BV, Hemphill RR. Suicide and suicide attempts on hospital grounds and clinic areas. J
Patient Saf. 2021;17(5):e423-e428. doi:10.1097/pts.0000000000000356.
https://psnet.ahrq.gov/issue/suicide-and-suicide-attempts-hos…
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psnet.ahrq.gov/node/47217/psn-pdf
June 27, 2018 - Drug shortages roundtable: minimizing the impact on
patient care.
June 27, 2018
Drug shortages roundtable: Minimizing the impact on patient care. Am J Health Syst Pharm.
2018;75(11):816-820. doi:10.2146/ajhp180048.
https://psnet.ahrq.gov/issue/drug-shortages-roundtable-minimizing-impact-patient-care
This commenta…
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psnet.ahrq.gov/node/47503/psn-pdf
October 24, 2018 - I-PASS checklist: a powerful tool for patient handoffs.
October 24, 2018
Peeples L. Pharmacy Practice News. October 10, 2018.
https://psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs
Structured handoffs can reduce communication problems that contribute to medical error. This magazine
article re…
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psnet.ahrq.gov/node/45841/psn-pdf
March 01, 2017 - Monitoring the anaesthetist in the operating
theatre—professional competence and patient safety.
March 1, 2017
Larsson J. Monitoring the anaesthetist in the operating theatre - professional competence and patient
safety. Anaesthesia. 2017;72 Suppl 1:76-83. doi:10.1111/anae.13743.
https://psnet.ahrq.gov/issue/monit…
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psnet.ahrq.gov/node/47979/psn-pdf
May 01, 2019 - Inpatient notes: just what the doctor ordered—checklists
to improve diagnosis.
May 1, 2019
Gupta A, Graber ML. Web Exclusive. Annals for Hospitalists Inpatient Notes - Just What the Doctor
Ordered-Checklists to Improve Diagnosis. Ann Intern Med. 2019;170(8):HO2-HO3. doi:10.7326/M19-0829.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/60286/psn-pdf
April 29, 2020 - With Covid-19 delaying routine care, chronic disease
startups brace for a slew of complications.
April 29, 2020
Brodwin E. STAT. April 14, 2020.
https://psnet.ahrq.gov/issue/covid-19-delaying-routine-care-chronic-disease-startups-brace-slew-
complications
Patients with cancer and other chronic disorder treatment …
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psnet.ahrq.gov/node/37444/psn-pdf
January 02, 2008 - My brother's keeper: must a physician disclose another's
medical error and potential negligence?
January 2, 2008
Liang BA, Smith C by DS. My brother's keeper: must a physician disclose another's medical error and
potential negligence? J Clin Anesth. 2007;19(7):558-562. doi:10.1016/j.jclinane.2007.05.005.
https://p…
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psnet.ahrq.gov/node/43585/psn-pdf
July 16, 2015 - At risk care plans: a way to reduce readmissions and
adverse events.
July 16, 2015
Bahle J, Majercik C, Ludwick R, et al. At Risk Care Plans: a way to reduce readmissions and adverse
events. J Nurs Care Qual. 2015;30(3):200-4. doi:10.1097/NCQ.0000000000000106.
https://psnet.ahrq.gov/issue/risk-care-plans-way-reduc…
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psnet.ahrq.gov/node/45993/psn-pdf
January 01, 2021 - 30-day potentially avoidable readmissions due to adverse
drug events.
May 3, 2017
Dalleur O, Beeler PE, Schnipper JL, et al. 30-Day Potentially Avoidable Readmissions Due to Adverse
Drug Events. J Patient Saf. 2021;17(5):e379-e386. doi:10.1097/pts.0000000000000346.
https://psnet.ahrq.gov/issue/30-day-potentially-a…
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psnet.ahrq.gov/node/44118/psn-pdf
May 19, 2018 - Inadequate preoperative team briefings lead to more
intraoperative adverse events.
May 19, 2018
Phadnis J, Templeton-Ward O. Inadequate Preoperative Team Briefings Lead to More Intraoperative
Adverse Events. J Patient Saf. 2018;14(2):82-86. doi:10.1097/PTS.0000000000000181.
https://psnet.ahrq.gov/issue/inadequate-…
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psnet.ahrq.gov/node/43149/psn-pdf
July 23, 2014 - FDASIA Health IT Report: Proposed Strategy and
Recommendations for a Risk-Based Framework.
July 23, 2014
Washington, DC: Office of the National Coordinator for Health Information Technology, Federal
Communications Commission. Silver Spring, MD: Food and Drug Administration. April 2014.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/836726/psn-pdf
March 09, 2022 - OpenNotes and patient safety: a perilous voyage into
uncharted waters.
March 9, 2022
Schust G, Manning M, Weil A. OpenNotes and patient safety: a perilous voyage into uncharted waters. J
Gen Intern Med. 2022;37(8):2074-2076. doi:10.1007/s11606-021-07384-2.
https://psnet.ahrq.gov/issue/opennotes-and-patient-safety-…
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psnet.ahrq.gov/node/37737/psn-pdf
January 06, 2017 - Can patient safety be measured by surveys of patient
experiences?
January 6, 2017
Solberg LI, Asche SE, Averbeck BM, et al. Can patient safety be measured by surveys of patient
experiences? Jt Comm J Qual Patient Saf. 2008;34(5):266-274.
https://psnet.ahrq.gov/issue/can-patient-safety-be-measured-surveys-patient-e…
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psnet.ahrq.gov/node/45713/psn-pdf
November 22, 2017 - Assigning responsibility to close the loop on radiology
test results.
November 22, 2017
Kwan JL, Singh H. Assigning responsibility to close the loop on radiology test results. Diagnosis (Berl).
2017;4(3):173-177. doi:10.1515/dx-2017-0019.
https://psnet.ahrq.gov/issue/assigning-responsibility-close-loop-radiology-t…
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psnet.ahrq.gov/node/74753/psn-pdf
February 09, 2022 - The morbidity and mortality conference: opportunities for
enhancing patient safety.
February 9, 2022
Lazzara EH, Salisbury M, Hughes AM, et al. The morbidity and mortality conference: opportunities for
enhancing patient safety. J Patient Saf. 2022;18(1):e275-e281. doi:10.1097/pts.0000000000000765.
https://psnet.ah…
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January 01, 2021 - Cognitive bias impact on management of postoperative
complications, medical error, and standard of care.
November 4, 2020
Antonacci AC, Dechario SP, Antonacci C, et al. Cognitive bias impact on management of postoperative
complications, medical error, and standard of care. J Surg Res. 2021;258:47-53.
doi:10.1016/j…