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psnet.ahrq.gov/issue/outcomes-two-massachusetts-hospital-systems-give-reason-optimism-about-communication-and
December 19, 2018 - Study
Outcomes in two Massachusetts hospital systems give reason for optimism about communication-and-resolution programs.
Citation Text:
Mello MM, Kachalia A, Roche S, et al. Outcomes In Two Massachusetts Hospital Systems Give Reason For Optimism About Communication-And-Resolution Progr…
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psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-chemotherapy-preparation-process
March 09, 2022 - Study
Healthcare failure mode and effect analysis in the chemotherapy preparation process.
Citation Text:
Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. Healthcare failure mode and effect analysis in the chemotherapy preparation process. J Oncol Pharm Pract. 2021;27(7):15…
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psnet.ahrq.gov/issue/parent-perceptions-childrens-hospital-safety-climate
December 22, 2018 - Study
Parent perceptions of children's hospital safety climate.
Citation Text:
Cox E, Carayon P, Hansen KW, et al. Parent perceptions of children's hospital safety climate. BMJ Qual Saf. 2013;22(8):664-71. doi:10.1136/bmjqs-2012-001727.
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psnet.ahrq.gov/issue/low-literacy-impairs-comprehension-prescription-drug-warning-labels
January 21, 2009 - Study
Low literacy impairs comprehension of prescription drug warning labels.
Citation Text:
Davis TC, Wolf MS, Bass PF, et al. Low literacy impairs comprehension of prescription drug warning labels. J Gen Intern Med. 2006;21(8):847-51.
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psnet.ahrq.gov/issue/improving-patient-safety-five-years-after-iom-report
February 18, 2011 - Commentary
Classic
Improving patient safety—five years after the IOM report.
Citation Text:
Altman DE, Clancy CM, Blendon RJ. Improving Patient Safety — Five Years after the IOM Report. New Engl J Med. 2004;351(20):2041-2043. doi:10.1056/nejmp048243.
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psnet.ahrq.gov/issue/medication-safety-messages-patients-web-portal-medcheck-intervention
September 11, 2013 - Study
Medication safety messages for patients via the web portal: the MedCheck intervention.
Citation Text:
Weingart SN, Hamrick HE, Tutkus S, et al. Medication safety messages for patients via the web portal: the MedCheck intervention. Int J Med Inform . 2008;77(3):161-168.
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psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-comparison-two-common-risk-prioritisation-methods
September 09, 2015 - Study
Failure mode and effects analysis: a comparison of two common risk prioritisation methods.
Citation Text:
McElroy LM, Khorzad R, Nannicelli AP, et al. Failure mode and effects analysis: a comparison of two common risk prioritisation methods. BMJ Qual Saf. 2016;25(5):329-336. doi:10…
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psnet.ahrq.gov/issue/patient-perspectives-patient-provider-communication-after-adverse-events
March 28, 2011 - Study
Patient perspectives of patient–provider communication after adverse events.
Citation Text:
Duclos CW, Eichler M, Taylor L, et al. Patient perspectives of patient-provider communication after adverse events. Int J Qual Health Care. 2005;17(6):479-86.
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psnet.ahrq.gov/issue/improving-diagnosis-health-care
September 12, 2018 - Book/Report
Classic
Improving Diagnosis in Health Care.
Citation Text:
Improving Diagnosis in Health Care. Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2015. ISB…
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psnet.ahrq.gov/issue/effect-organizational-network-patient-safety-safety-event-reporting
October 16, 2013 - Study
The effect of an organizational network for patient safety on safety event reporting.
Citation Text:
Jeffs L, Hayes C, Smith O, et al. The effect of an organizational network for patient safety on safety event reporting. Eval Health Prof. 2014;37(3):366-78. doi:10.1177/016327871349…
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psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
July 01, 2008 - considerable information technology work is necessary to ensure that all data flow appropriately, with correct
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - error is inevitable in human (or electronic) processes, resilient systems are designed to identify and correct
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - SPOTLIGHT CASE
Do Not Disturb!
Citation Text:
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - SPOTLIGHT CASE
Multifactorial Medication Mishap
Citation Text:
Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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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/wrong-side-thoracentesis-lessons-learned-root-cause-analysis
July 16, 2015 - Study
Wrong-side thoracentesis: lessons learned from root cause analysis.
Citation Text:
Miller K, Mims M, Paull DE, et al. Wrong-side thoracentesis: lessons learned from root cause analysis. JAMA Surg. 2014;149(8):774-9. doi:10.1001/jamasurg.2014.146.
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psnet.ahrq.gov/node/845473/psn-pdf
March 15, 2023 - To support the correct use of devices according to guidelines and avoid false values, organizations should
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psnet.ahrq.gov/node/867651/psn-pdf
February 26, 2025 - As such, incorrectly functioning
components (including people), must be addressed to transition to correct
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psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
October 02, 2024 - As such, incorrectly functioning components (including people), must be addressed to transition to correct
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psnet.ahrq.gov/issue/patients-concerns-about-medical-errors-during-hospitalization
December 22, 2008 - Study
Classic
Patients' concerns about medical errors during hospitalization.
Citation Text:
Burroughs TE, Waterman AD, Gallagher TH, et al. Patients' concerns about medical errors during hospitalization. Jt Comm J Qual Patient Saf. 2007;33(1):5-14.
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