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psnet.ahrq.gov/node/41726/psn-pdf
September 26, 2012 - Improving America's Hospitals: The Joint Commission's
Annual Report on Quality and Safety 2012.
September 26, 2012
Oakbrook Terrace, IL: The Joint Commission; September 2012.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety-2012
The seventh annual Joint…
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psnet.ahrq.gov/node/42692/psn-pdf
April 21, 2015 - Surgical skill and complication rates after bariatric
surgery.
April 21, 2015
Birkmeyer JD, Finks JF, O'Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl
J Med. 2013;369(15):1434-1442. doi:10.1056/NEJMsa1300625.
https://psnet.ahrq.gov/issue/surgical-skill-and-complication-rates…
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psnet.ahrq.gov/node/34669/psn-pdf
June 26, 2015 - Learning from mistakes is easier said than done: group
and organizational influences on the detection and
correction of human error.
June 26, 2015
Edmondson AC. Learning from Mistakes is Easier Said Than Done: Group and Organizational Influences
on the Detection and Correction of Human Error. J Appl Behav Sci. 200…
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psnet.ahrq.gov/node/46267/psn-pdf
December 21, 2017 - Pictograms, units and dosing tools, and parent
medication errors: a randomized study.
December 21, 2017
Yin S, Parker RM, Sanders LM, et al. Pictograms, Units and Dosing Tools, and Parent Medication Errors: A
Randomized Study. Pediatrics. 2017;140(1):e20163237. doi:10.1542/peds.2016-3237.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/45538/psn-pdf
December 14, 2016 - Liquid medication errors and dosing tools: a randomized
controlled experiment.
December 14, 2016
Yin S, Parker RM, Sanders LM, et al. Liquid Medication Errors and Dosing Tools: A Randomized Controlled
Experiment. Pediatrics. 2016;138(4):e20160357.
https://psnet.ahrq.gov/issue/liquid-medication-errors-and-dosing-to…
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psnet.ahrq.gov/node/36697/psn-pdf
February 03, 2011 - Deficits in communication and information transfer
between hospital-based and primary care physicians:
implications for patient safety and continuity of care.
February 3, 2011
Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between
hospital-based and primary care phys…
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psnet.ahrq.gov/node/43694/psn-pdf
November 17, 2015 - Relationships within inpatient physician housestaff teams
and their association with hospitalized patient outcomes.
November 17, 2015
McAllister C, Leykum LK, Lanham H, et al. Relationships within inpatient physician housestaff teams and
their association with hospitalized patient outcomes. J Hosp Med. 2014;9(12):7…
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psnet.ahrq.gov/node/42266/psn-pdf
May 15, 2013 - Medication errors in the home: a multisite study of
children with cancer.
May 15, 2013
Walsh KE, Roblin DW, Weingart SN, et al. Medication errors in the home: a multisite study of children with
cancer. Pediatrics. 2013;131(5):e1405-14. doi:10.1542/peds.2012-2434.
https://psnet.ahrq.gov/issue/medication-errors-home…
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psnet.ahrq.gov/node/45410/psn-pdf
July 27, 2018 - Allocation of physician time in ambulatory practice: a
time and motion study in four specialties.
July 27, 2018
Sinsky CA, Colligan L, Li L, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion
Study in 4 Specialties. Ann Intern Med. 2016;165(11). doi:10.7326/m16-0961.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/44963/psn-pdf
January 23, 2017 - The frequency of intravenous medication administration
errors related to smart infusion pumps: a multihospital
observational study.
January 23, 2017
Schnock KO, Dykes PC, Albert J, et al. The frequency of intravenous medication administration errors
related to smart infusion pumps: a multihospital observational st…
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psnet.ahrq.gov/node/847537/psn-pdf
April 12, 2023 - Measuring team hierarchy during high-stakes clinical
decision making: development and validation of a new
behavioral observation method.
April 12, 2023
Johansson AC, Manago B, Sell J, et al. Measuring team hierarchy during high-stakes clinical decision
making: development and validation of a new behavioral observa…
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psnet.ahrq.gov/node/46459/psn-pdf
August 20, 2018 - Readiness of US general surgery residents for
independent practice.
August 20, 2018
George BC, Bohnen JD, Williams RG, et al. Readiness of US General Surgery Residents for Independent
Practice. Ann Surg. 2017;266(4):582-594. doi:10.1097/SLA.0000000000002414.
https://psnet.ahrq.gov/issue/readiness-us-general-surger…
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psnet.ahrq.gov/node/73704/psn-pdf
September 15, 2021 - TRIAD IX: can a patient testimonial safely help ensure
prehospital appropriate critical versus end-of-life care?
September 15, 2021
Mirarchi FL, Cammarata C, Cooney TE, et al. TRIAD IX: can a patient testimonial safely help ensure
prehospital appropriate critical versus end-of-life care? J Patient Saf. 2021;17(6):4…
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psnet.ahrq.gov/node/37997/psn-pdf
June 16, 2011 - Revealing and resolving patient safety defects: the impact
of leadership WalkRounds on frontline caregiver
assessments of patient safety.
June 16, 2011
Frankel A, Grillo SP, Pittman M, et al. Revealing and resolving patient safety defects: the impact of
leadership WalkRounds on frontline caregiver assessments of p…
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psnet.ahrq.gov/node/34688/psn-pdf
March 28, 2005 - Adverse drug events in hospitalized patients: excess
length of stay, extra costs, and attributable mortality.
March 28, 2005
Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients. Excess length of
stay, extra costs, and attributable mortality. JAMA. 1997;277(4):301-6.
https://psne…
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psnet.ahrq.gov/node/47787/psn-pdf
February 20, 2019 - How to be a very safe maternity unit: an ethnographic
study.
February 20, 2019
Liberati EG, Tarrant C, Willars J, et al. How to be a very safe maternity unit: An ethnographic study. Soc
Sci Med. 2019;223:64-72. doi:10.1016/j.socscimed.2019.01.035.
https://psnet.ahrq.gov/issue/how-be-very-safe-maternity-unit-ethnog…
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psnet.ahrq.gov/node/866081/psn-pdf
June 05, 2024 - "The patient is awake and we need to stay calm":
reconsidering indirect communication in the face of
medical error and professionalism lapses.
June 5, 2024
Taylor T, Columbus L, Banner H, et al. “The patient is awake and we need to stay calm”: reconsidering
indirect communication in the face of medical error and p…
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psnet.ahrq.gov/node/39193/psn-pdf
April 21, 2011 - Disclosing harmful mammography errors to patients.
April 21, 2011
Gallagher TH, Cook AJ, Brenner RJ, et al. Disclosing Harmful Mammography Errors to Patients. Radiology.
2009;253(2). doi:10.1148/radiol.2532082320.
https://psnet.ahrq.gov/issue/disclosing-harmful-mammography-errors-patients
Disclosing errors to pati…
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psnet.ahrq.gov/node/42836/psn-pdf
January 08, 2014 - Comparison of medication safety effectiveness among
nine critical access hospitals.
January 8, 2014
Cochran GL, Haynatzki G. Comparison of medication safety effectiveness among nine critical access
hospitals. Am J Health Syst Pharm. 2013;70(24):2218-24. doi:10.2146/ajhp130067.
https://psnet.ahrq.gov/issue/comparis…
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psnet.ahrq.gov/node/40539/psn-pdf
June 22, 2011 - Medication administration errors in assisted living: scope,
characteristics, and the importance of staff training.
June 22, 2011
Zimmerman S, Love K, Sloane PD, et al. Medication administration errors in assisted living: scope,
characteristics, and the importance of staff training. J Am Geriatr Soc. 2011;59(6):1060…