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psnet.ahrq.gov/issue/understanding-vs-competency-case-accuracy-checking-dispensed-medicines-pharmacy
December 11, 2013 - Study
Understanding vs. competency: the case of accuracy checking dispensed medicines in pharmacy.
Citation Text:
James L, Davies G, Kinchin I, et al. Understanding vs. competency: the case of accuracy checking dispensed medicines in pharmacy. Adv Health Sci Educ Theory Pract. 2010;15(…
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psnet.ahrq.gov/issue/analysis-near-misses-identified-anesthesia-providers-intensive-care-unit
August 17, 2017 - Study
An analysis of near misses identified by anesthesia providers in the intensive care unit.
Citation Text:
Lipshutz AKM, Caldwell JE, Robinowitz DL, et al. An analysis of near misses identified by anesthesia providers in the intensive care unit. BMC Anesthesiol. 2015;15:93. doi:10.11…
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psnet.ahrq.gov/issue/seips-30-human-centered-design-patient-journey-patient-safety
September 11, 2019 - Review
Classic
SEIPS 3.0: human-centered design of the patient journey for patient safety.
Citation Text:
Carayon P, Wooldridge AR, Hoonakker P, et al. SEIPS 3.0: human-centered design of the patient journey for patient safety. App Ergon. 2020;84:103033. doi:10…
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psnet.ahrq.gov/issue/americans-experiences-medical-errors-and-views-patient-safety
January 06, 2015 - Book/Report
Classic
Americans' Experiences With Medical Errors and Views on Patient Safety.
Citation Text:
Americans' Experiences With Medical Errors and Views on Patient Safety. Chicago, IL: NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute;…
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psnet.ahrq.gov/issue/frequency-medication-administration-timing-error-hospitals-systematic-review
March 15, 2023 - Review
Frequency of medication administration timing error in hospitals: a systematic review.
Citation Text:
Pullam T, Russell CL, White-Lewis S. Frequency of medication administration timing error in hospitals: a systematic review. J Nurs Care Qual. 2023;38(2):126-133. doi:10.1097/ncq.0…
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psnet.ahrq.gov/issue/hospital-ward-incidents-through-eyes-nurses-thick-description-appeal-and-deadlock-incident
November 15, 2023 - Study
Hospital ward incidents through the eyes of nurses – a thick description on the appeal and deadlock of incident reporting systems.
Citation Text:
Tresfon J, van Winsen R, Brunsveld-Reinders AH, et al. Hospital ward incidents through the eyes of nurses - a thick description on the a…
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psnet.ahrq.gov/issue/just-culture-foundation-staff-safety-perioperative-environment
June 09, 2021 - Commentary
Just culture: the foundation of staff safety in the perioperative environment.
Citation Text:
Fencl JL, Willoughby C, Jackson K. Just culture: the foundation of staff safety in the perioperative environment. AORN J. 2021;113(4):329-336. doi:10.1002/aorn.13352.
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psnet.ahrq.gov/issue/health-system-resilience-accreditation-high-quality-care-and-continuous-quality-improvement
November 25, 2020 - Commentary
Health system resilience, accreditation, high-quality care, and continuous quality improvement: what is the destination and how do we get there?
Citation Text:
Nicklin W, Greenfield D. Health system resilience, accreditation, high-quality care, and continuous quality improveme…
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psnet.ahrq.gov/issue/standardized-competencies-parenteral-nutrition-prescribing-american-society-parenteral-and
February 17, 2015 - Commentary
Standardized competencies for parenteral nutrition prescribing: The American Society for Parenteral and Enteral Nutrition Model.
Citation Text:
Guenter P, Boullata JI, Ayers P, et al. Standardized Competencies for Parenteral Nutrition Prescribing: The American Society for Pare…
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psnet.ahrq.gov/issue/medical-errors-and-patient-safety-palliative-care-review-current-literature
December 04, 2016 - Review
Medical errors and patient safety in palliative care: a review of current literature.
Citation Text:
Dietz I, Borasio GD, Schneider G, et al. Medical errors and patient safety in palliative care: a review of current literature. J Palliat Med. 2010;13(12):1469-74. doi:10.1089/jpm.2…
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psnet.ahrq.gov/issue/root-cause-analysis-reported-patient-falls-ors-veterans-health-administration
January 17, 2019 - Commentary
Root cause analysis of reported patient falls in ORs in the Veterans Health Administration.
Citation Text:
Soncrant CM, Warner LJ, Neily J, et al. Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration. AORN J. 2018;108(4):386-397. doi:10.10…
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psnet.ahrq.gov/issue/utilizing-pharmacy-students-transitions-care-services
October 19, 2022 - Commentary
Utilizing pharmacy students in transitions-of-care services.
Citation Text:
L'Hommedieu T, DeCoske M, Lababidi RE, et al. Utilizing pharmacy students in transitions-of-care services. Am J Health Syst Pharm. 2015;72(15):1266-8. doi:10.2146/ajhp140561.
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psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
December 27, 2019 - Mental health was actually a trailblazer for defining cultural competence and I wrote a bit on the subject
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psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
August 28, 2024 - Rather than defining safety as the absence of adverse events, where as few things as possible go wrong
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psnet.ahrq.gov/perspective/application-safety-ii-principles
August 28, 2024 - Rather than defining safety as the absence of adverse events, where as few things as possible go wrong
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psnet.ahrq.gov/node/865455/psn-pdf
March 27, 2024 - Communication During Transitions of Care
March 27, 2024
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/communication-during-transitions-care
Introduction
Inaccurate or untimely communication and ineffective teamwork in healthca…
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psnet.ahrq.gov/node/33690/psn-pdf
December 01, 2009 - In Conversation with…Gerald B. Hickson, MD
December 1, 2009
In Conversation with…Gerald B. Hickson, MD . PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
Editor's note: Gerald B. Hickson, MD, is one of the world's leading experts on physician behavior and its
connecti…
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psnet.ahrq.gov/curated-library/organizational-learning
August 11, 2025 - Breadcrumb
Home
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Curated Libraries
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team…
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psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
November 16, 2022 - Annual Perspective
Annual Perspective: Psychological Safety of Healthcare Staff
March 31, 2022
View more articles from the same authors.
Citation Text:
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. P…
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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - SPOTLIGHT CASE
Bad Writing, Wrong Medication
Citation Text:
Devine B. Bad Writing, Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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