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psnet.ahrq.gov/node/47840/psn-pdf
July 31, 2019 - Development and performance evaluation of the
Medicines Optimisation Assessment Tool (MOAT): a
prognostic model to target hospital pharmacists' input to
prevent medication-related problems.
July 31, 2019
Geeson C, Wei L, Franklin BD. Development and performance evaluation of the Medicines Optimisation
Assessment …
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psnet.ahrq.gov/node/837510/psn-pdf
June 22, 2022 - In situ simulation for adoption of new technology to
improve sepsis care in rural emergency departments.
June 22, 2022
Powell ES, Bond WF, Barker LT, et al. In situ simulation for adoption of new technology to improve sepsis
care in rural emergency departments. J Patient Saf. 2022;18(4):302-309.
doi:10.1097/pts.00…
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psnet.ahrq.gov/node/49855/psn-pdf
March 01, 2019 - Which Line: Ordering Provider or Proceduralist?
March 1, 2019
Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
Case Objectives
Review the role of mistake-proofing to block errors from leading to adverse…
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psnet.ahrq.gov/issue/interim-report-review-vhas-patient-wait-times-scheduling-practices-and-alleged-patient-deaths
September 10, 2014 - Government Resource
Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.
Citation Text:
Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix H…
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psnet.ahrq.gov/issue/qualitative-study-speaking-out-about-patient-safety-concerns-intensive-care-units
August 21, 2013 - Study
A qualitative study of speaking out about patient safety concerns in intensive care units.
Citation Text:
Tarrant C, Leslie M, Bion J, et al. A qualitative study of speaking out about patient safety concerns in intensive care units. Soc Sci Med. 2017;193:8-15. doi:10.1016/j.socscim…
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psnet.ahrq.gov/node/43949/psn-pdf
November 17, 2016 - Clinical criteria to screen for inpatient diagnostic errors: a
scoping review.
November 17, 2016
Shenvi EC, El-Kareh R. Clinical criteria to screen for inpatient diagnostic errors: a scoping review.
Diagnosis (Berl). 2015;2(1):3-19. doi:10.1515/dx-2014-0047.
https://psnet.ahrq.gov/issue/clinical-criteria-screen-in…
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psnet.ahrq.gov/node/46527/psn-pdf
March 07, 2018 - When missing a 'zebra' can land you in court.
March 7, 2018
Crane M. Medscape Business of Medicine. February 20, 2018.
https://psnet.ahrq.gov/issue/when-missing-zebra-can-land-you-court
Cognitive biases contribute to missed diagnoses. This article discusses how cognitive biases affect
decision making associated wi…
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psnet.ahrq.gov/node/73257/psn-pdf
December 01, 2021 - Peer Review of a Report on Strategies to Improve Patient
Safety.
May 12, 2021
Washington DC: National Academies of Sciences, Engineering, and Medicine; 2021. ISBN:
9780309462808.
https://psnet.ahrq.gov/issue/peer-review-report-strategies-improve-patient-safety
The Patient Safety and Quality Improvement Act of 200…
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psnet.ahrq.gov/node/47926/psn-pdf
May 22, 2019 - The Canadian Quality and Patient Safety Framework for
Health and Social Services.
May 22, 2019
Canadian Patient Safety Institute and Health Standards Organization.
https://psnet.ahrq.gov/issue/canadian-quality-and-patient-safety-framework-health-and-social-services
This 5-year framework aims to guide the activitie…
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psnet.ahrq.gov/node/50748/psn-pdf
December 18, 2019 - Systematic review of interventions to improve safety and
quality of anticoagulant prescribing for therapeutic
indications for hospital inpatients
December 18, 2019
Frazer A, Rowland J, Mudge A, et al. Eur J Clin Pharmacol. 2019;75(12):1645-1657.
https://psnet.ahrq.gov/issue/systematic-review-interventions-imp…
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psnet.ahrq.gov/node/73501/psn-pdf
July 14, 2021 - Deficiencies in Emergency Preparedness for Veterans
Health Administration Telemental Health Care at VA Clinic
Locations Prior to the Pandemic.
July 14, 2021
Washington, DC: Department of Veterans Affairs, Office of Inspector General. June 24, 2021. Report No.
19-09808-171.
https://psnet.ahrq.gov/issue/deficiencie…
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psnet.ahrq.gov/node/60543/psn-pdf
May 27, 2020 - Wrong Catheter in the Right Patient
May 27, 2020
Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
The Case
A 55-year-old man with history of emphysema was admitted to the hospital for pneumonia. The patient had
two?peripheral…
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psnet.ahrq.gov/node/37118/psn-pdf
October 04, 2011 - Knowledge translation in critical care: factors associated
with prescription of commonly recommended best
practices for critically ill patients.
October 4, 2011
Ilan R, Fowler RA, Geerts R, et al. Knowledge translation in critical care: factors associated with
prescription of commonly recommended best practices fo…
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psnet.ahrq.gov/node/36198/psn-pdf
March 28, 2011 - Using human error theory to explore the supply of non-
prescription medicines from community pharmacies.
March 28, 2011
Watson MC, Bond CM, Johnston M, et al. Using human error theory to explore the supply of non-
prescription medicines from community pharmacies. Qual Saf Health Care. 2006;15(4):244-50.
https://ps…
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psnet.ahrq.gov/node/41107/psn-pdf
May 04, 2012 - A prospective, multicenter study of pharmacist activities
resulting in medication error interception in the
emergency department.
May 4, 2012
Patanwala AE, Sanders AB, Thomas MC, et al. A prospective, multicenter study of pharmacist activities
resulting in medication error interception in the emergency department.…
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psnet.ahrq.gov/node/34661/psn-pdf
March 07, 2005 - Teaching smart people how to learn.
March 7, 2005
Argyris C. Harvard Business Review. 1991:69(May-June):99+.
https://psnet.ahrq.gov/issue/teaching-smart-people-learn
Argyris, a Harvard Business School professor, theorizes that companies and organizations must learn in
order to continually improve and succeed, but …
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - Once involved in a case, they may have difficult time backing off and admitting it is time for a consultant … Call a consultant, get a test, double back around to another consultant, cancel another test, and stop
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psnet.ahrq.gov/node/73710/psn-pdf
September 15, 2021 - Strengths and weaknesses in the diagnostic process of
endometriosis from the patients' perspective: a focus
group study.
September 15, 2021
van der Zanden M, de Kok L, Nelen WLDM, et al. Strengths and weaknesses in the diagnostic process of
endometriosis from the patients’ perspective: a focus group study. Diagnos…
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psnet.ahrq.gov/node/60340/psn-pdf
May 20, 2020 - Association between cancer-specific adverse event
triggers and mortality: a validation study.
May 20, 2020
Weingart SN, Nelson J, Koethe B, et al. Association between cancer?specific adverse event triggers and
mortality: A validation study. Cancer Med. 2020;9(12):4447-4459. doi:10.1002/cam4.3033.
https://psnet.ahr…
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psnet.ahrq.gov/node/837899/psn-pdf
August 24, 2022 - Feelings of trust and of safety are related facets of the
patient's experience in surgery: a descriptive qualitative
study in 80 patients.
August 24, 2022
Occelli P, Mougeot F, Robelet M, et al. Feelings of trust and of safety are related facets of the patient's
experience in surgery: a descriptive qualitative stu…