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psnet.ahrq.gov/node/38060/psn-pdf
April 11, 2011 - Iatrogenesis in neonatal intensive care units:
observational and interventional, prospective, multicenter
study.
April 11, 2011
Kugelman A, Inbar-Sanado E, Shinwell ES, et al. Iatrogenesis in neonatal intensive care units:
observational and interventional, prospective, multicenter study. Pediatrics. 2008;122(3):55…
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psnet.ahrq.gov/node/72582/psn-pdf
December 16, 2020 - Deficiencies in the Veterans Crisis Line Response to a
Veteran Caller Who Died.
December 16, 2020
Washington, DC: Department of Veterans Affairs, Office of Inspector General; November 17, 2020. Report
No 19-08542-11.
https://psnet.ahrq.gov/issue/deficiencies-veterans-crisis-line-response-veteran-caller-who-died
I…
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psnet.ahrq.gov/node/73185/psn-pdf
April 28, 2021 - Balancing patient safety, clinical efficacy, and
cybersecurity with clinician partners.
April 28, 2021
Schneider J, Wirth A. Balancing patient safety, clinical efficacy, and cybersecurity with clinician partners.
Biomed Instrum Technol. 2021;55(1):21-28. doi:10.2345/0899-8205-55.1.21.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/855099/psn-pdf
November 08, 2023 - Doctors wrestle with A.I. in patient care, citing lax
oversight.
November 8, 2023
Jewett C. New York Times. October 30, 2023
https://psnet.ahrq.gov/issue/doctors-wrestle-ai-patient-care-citing-lax-oversight
US Food and Drug Administration regulation and review is noted as having gaps in process that can affect
pa…
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psnet.ahrq.gov/node/46254/psn-pdf
October 09, 2017 - Using risk stratification to reduce medical errors in
cervical cancer prevention.
October 9, 2017
Perkins RB, Cain JM, Feldman S. Using Risk Stratification to Reduce Medical Errors in Cervical Cancer
Prevention. JAMA Intern Med. 2017;177(10):1411-1412. doi:10.1001/jamainternmed.2017.3999.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/46735/psn-pdf
January 31, 2018 - Influence of perceived difficulty of cases on student
osteopaths' diagnostic reasoning: a cross sectional
study.
January 31, 2018
Noyer AL, Esteves JE, Thomson OP. Influence of perceived difficulty of cases on student osteopaths'
diagnostic reasoning: a cross sectional study. Chiropr Man Therap. 2017;25:32. doi:10…
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psnet.ahrq.gov/node/37993/psn-pdf
August 20, 2008 - Peer support: healthcare professionals supporting each
other after adverse medical events.
August 20, 2008
van Pelt F. Peer support: healthcare professionals supporting each other after adverse medical events.
Qual Saf Health Care. 2008;17(4):249-52. doi:10.1136/qshc.2007.025536.
https://psnet.ahrq.gov/issue/peer-…
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psnet.ahrq.gov/node/48075/psn-pdf
June 19, 2019 - A mismatch made in America.
June 19, 2019
Butcher L. Managed Care. June 2019;28:37-39.
https://psnet.ahrq.gov/issue/mismatch-made-america
Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient
errors. This magazine article reports on the complex nature of addressing …
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psnet.ahrq.gov/node/33936/psn-pdf
May 27, 2011 - Computer physician order entry: benefits, costs, and
issues.
May 27, 2011
Kuperman GJ, Gibson RF. Computer physician order entry: benefits, costs, and issues. Ann Intern Med.
2003;139(1):31-9.
https://psnet.ahrq.gov/issue/computer-physician-order-entry-benefits-costs-and-issues
Using existing research, this revie…
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psnet.ahrq.gov/node/837212/psn-pdf
June 08, 2022 - Engaging Physicians in Teamwork Training for Quality
and Safety - Or Why Don’t Your Physicians Get Engaged?
May 25, 2022
AHA Team Training. June 8, 2022.
https://psnet.ahrq.gov/issue/engaging-physicians-teamwork-training-quality-and-safety-or-why-dont-your-
physicians-get
Physicians are instrumental to the succes…
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psnet.ahrq.gov/node/46138/psn-pdf
May 31, 2017 - An innovative collaborative model of care for
undiagnosed complex medical conditions.
May 31, 2017
Nageswaran S, Donoghue N, Mitchell A, et al. An Innovative Collaborative Model of Care for Undiagnosed
Complex Medical Conditions. Pediatrics. 2017;139(5):e20163373. doi:10.1542/peds.2016-3373.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/34592/psn-pdf
January 04, 2017 - John M. Eisenberg Patient Safety Awards. Advocacy: the
Lexington Veterans Affairs Medical Center.
January 4, 2017
Kraman SS, Cranfill L, Hamm G, et al. John M. Eisenberg Patient Safety Awards. Advocacy: the Lexington
Veterans Affairs Medical Center. Jt Comm J Qual Improv. 2002;28(12):646-50.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/838086/psn-pdf
September 14, 2022 - Addressing Burnout in the Behavioral Health Workforce
through Organizational Strategies.
September 14, 2022
Rockville, MD: Substance Abuse and Mental Health Services Administration; 2022. SAMHSA
Publication No. PEP22-06-02-005.
https://psnet.ahrq.gov/issue/addressing-burnout-behavioral-health-workforce-throu…
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psnet.ahrq.gov/node/46946/psn-pdf
January 01, 2019 - Speaking up about patient safety concerns: the influence
of safety management approaches and climate on nurses'
willingness to speak up.
December 31, 2018
Alingh CW, van Wijngaarden JDH, van de Voorde K, et al. Speaking up about patient safety concerns: the
influence of safety management approaches and climate on …
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psnet.ahrq.gov/node/41701/psn-pdf
September 26, 2019 - The CUSP Method
September 26, 2019
The CUSP Method.
https://psnet.ahrq.gov/issue/cusp-method
The Comprehensive Unit-based Safety Program (CUSP), originally developed at Johns Hopkins Hospital
by Dr. Peter Pronovost and colleagues, has been instrumental in driving patient safety improvement in
several landmark pat…
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psnet.ahrq.gov/node/44821/psn-pdf
December 05, 2022 - Action Planning Tool for the AHRQ Surveys on Patient
Safety Culture.
December 5, 2022
Yount N, Edelman S, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; November
2022. AHRQ Publication No. 23-0011.
https://psnet.ahrq.gov/issue/action-planning-tool-ahrq-surveys-patient-safety-culture
Im…
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psnet.ahrq.gov/node/34771/psn-pdf
May 06, 2016 - Managing the Unexpected: Sustained Performance in a
Complex World, Third Edition.
May 6, 2016
Weick KE, Sutcliffe KM. San Francisco, CA: Jossey-Bass; 2015. ISBN-13: 9781118862414.
https://psnet.ahrq.gov/issue/managing-unexpected-sustained-performance-complex-world-3rd-edition
According to Weick and Sutcliffe, high…
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psnet.ahrq.gov/node/46749/psn-pdf
April 04, 2018 - Toolkit for Improving Perinatal Safety.
April 4, 2018
Rockville, MD: Agency for Healthcare Research and Quality. June 2017.
https://psnet.ahrq.gov/issue/toolkit-improving-perinatal-safety
Communication in labor and delivery units can be challenging. This AHRQ-funded program draws from
comprehensive unit-based safe…
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psnet.ahrq.gov/node/867348/psn-pdf
December 11, 2024 - Mind the sentinel - applying patient-safety paradigms to
clinician well-being.
December 11, 2024
Humikowski CA. Mind the sentinel - applying patient-safety paradigms to clinician well-being. N Engl J
Med. 2024;391(20):1870-1872. doi:10.1056/nejmp2406074.
https://psnet.ahrq.gov/issue/mind-sentinel-applying-patient-…
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psnet.ahrq.gov/node/867094/psn-pdf
January 01, 2025 - Maximizing the ability of health IT and AI to improve
patient safety.
November 6, 2024
Singh H, Sittig DF, Classen DC. Maximizing the ability of health IT and AI to improve patient safety. JAMA
Intern Med. 2025;185(1):10-12. doi:10.1001/jamainternmed.2024.4343.
https://psnet.ahrq.gov/issue/maximizing-ability-healt…