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psnet.ahrq.gov/node/848365/psn-pdf
May 03, 2023 - Value of improving patient safety: health economic
considerations for rapid response systems-a rapid review
of the literature and expert round table.
May 3, 2023
Subbe CP, Hughes DA, Lewis S, et al. Value of improving patient safety: health economic considerations
for rapid response systems–a rapid review of the l…
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psnet.ahrq.gov/node/45939/psn-pdf
March 01, 2017 - Examining the Copy and Paste Function in the Use of
Electronic Health Records.
March 1, 2017
Lowry SZ, Ramaiah M, Prettyman SS, et al. Gaithersburg, MD: National Institute of Standards and
Technology, United States Department of Commerce; January 19, 2017. NIST Interagency/Internal Report
(NISTIR)-8166.
https://p…
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psnet.ahrq.gov/node/60896/psn-pdf
January 01, 2021 - Bias at warp speed: how AI may contribute to the
disparities gap in the time of COVID-19.
September 9, 2020
Röösli E, Rice B, Hernandez-Boussard T. Bias at Warp Speed: How AI may Contribute to the Disparities
Gap in the Time of COVID-19. J Am Med Inform Assoc. 2021;28(1):190-192. doi:10.1093/jamia/ocaa210.
https:/…
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psnet.ahrq.gov/node/47857/psn-pdf
June 14, 2019 - The wicked problem of patient misidentification: how
could the technological revolution help address patient
safety?
June 14, 2019
Ferguson C, Hickman L, Macbean C, et al. The wicked problem of patient misidentification: How could the
technological revolution help address patient safety? J Clin Nurs. 2019;28(13-14…
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psnet.ahrq.gov/node/47679/psn-pdf
April 03, 2019 - 'So why didn't you think this baby was ill?' Decision-
making in acute paediatrics.
April 3, 2019
Roland D, Snelson E. 'So why didn't you think this baby was ill?' Decision-making in acute paediatrics. Arch
Dis Child Educ Pract Ed. 2019;104(1):43-48. doi:10.1136/archdischild-2017-313199.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/44587/psn-pdf
December 09, 2015 - Morbidity and mortality conference in emergency
medicine residencies and the culture of safety.
December 9, 2015
Aaronson E, Wittels KA, Nadel ES, et al. Morbidity and Mortality Conference in Emergency Medicine
Residencies and the Culture of Safety. West J Emerg Med. 2015;16(6):810-7.
doi:10.5811/westjem.2015.8.26…
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psnet.ahrq.gov/node/43342/psn-pdf
July 16, 2014 - Prevalence and severity of patient harm in a sample of
UK-hospitalised children detected by the Paediatric
Trigger Tool.
July 16, 2014
Chapman SM, Fitzsimons J, Davey N, et al. Prevalence and severity of patient harm in a sample of UK-
hospitalised children detected by the Paediatric Trigger Tool. BMJ Open. 2014;4…
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psnet.ahrq.gov/node/35207/psn-pdf
December 19, 2009 - Patient safety concerns arising from test results that
return after hospital discharge.
December 19, 2009
Roy CL, Poon EG, Karson A, et al. Patient safety concerns arising from test results that return after hospital
discharge. Ann Intern Med. 2005;143(2):121-128.
https://psnet.ahrq.gov/issue/patient-safety-concer…
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psnet.ahrq.gov/node/46249/psn-pdf
July 12, 2017 - Zero preventable deaths after traumatic injury: an
achievable goal.
July 12, 2017
Spinella PC. Zero preventable deaths after traumatic injury. J Trauma Acute Care Surg. 2017;82:S2-S8.
doi:10.1097/ta.0000000000001425.
https://psnet.ahrq.gov/issue/zero-preventable-deaths-after-traumatic-injury-achievable-goal
Criti…
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psnet.ahrq.gov/node/853244/psn-pdf
September 06, 2023 - Error traps in pediatric patient blood management in the
perioperative period.
September 6, 2023
Tan GM, Murto K, Downey LA, et al. Error traps in pediatric patient blood management in the perioperative
period. Paediatr Anaesth. 2023;33(8):609-619. doi:10.1111/pan.14683.
https://psnet.ahrq.gov/issue/error-traps-pe…
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psnet.ahrq.gov/node/43860/psn-pdf
March 25, 2015 - Pharmacy dispensing errors: claims study emphasizes
need for systematic vigilance.
March 25, 2015
Webb J. Drug Topics. March 10, 2015.
https://psnet.ahrq.gov/issue/pharmacy-dispensing-errors-claims-study-emphasizes-need-systematic-
vigilance
Pharmacies can serve as gatekeepers to ensure patients receive the corre…
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psnet.ahrq.gov/node/837433/psn-pdf
June 15, 2022 - Unacceptable behaviours between healthcare workers:
just the tip of the patient safety iceberg.
June 15, 2022
Bamberger E, Bamberger P. Unacceptable behaviours between healthcare workers: just the tip of the
patient safety iceberg. BMJ Qual Saf. 2022;31(9):638-641. doi:10.1136/bmjqs-2021-014157.
https://psnet.ahrq…
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psnet.ahrq.gov/node/35977/psn-pdf
February 17, 2011 - Making patient safety the centerpiece of medical liability
reform.
February 17, 2011
Clinton HR, Obama B. Making Patient Safety the Centerpiece of Medical Liability Reform. New England
Journal of Medicine. 2006;354(21). doi:10.1056/nejmp068100.
https://psnet.ahrq.gov/issue/making-patient-safety-centerpiece-medical…
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psnet.ahrq.gov/node/844789/psn-pdf
January 01, 2021 - Patient preferences in cases of Inter-system Medical Error
Discovery (IMED).
September 11, 2019
Antunez AG, Saari A, Miller J, et al. Patient Preferences in Cases of Inter-system Medical Error Discovery
(IMED). Ann Surg. 2021;273(3):516-522. doi:10.1097/SLA.0000000000003507.
https://psnet.ahrq.gov/issue/patient-pr…
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psnet.ahrq.gov/node/848084/psn-pdf
April 26, 2023 - Cognitive bias and dissonance in surgical practice: a
narrative review.
April 26, 2023
Richburg CE, Dossett LA, Hughes TM. Cognitive bias and dissonance in surgical practice: a narrative
review. Surg Clin North Am. 2023;103(2):271-285. doi:10.1016/j.suc.2022.11.003.
https://psnet.ahrq.gov/issue/cognitive-bias-and-…
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psnet.ahrq.gov/node/47024/psn-pdf
November 28, 2018 - FDA Safety Communication: use caution with implanted
pumps for intrathecal administration of medicines for
pain management.
November 28, 2018
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 14, 2018.
https://psnet.ahrq.gov/issue/fda-safety-communication-use-caution-implanted-pum…
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psnet.ahrq.gov/node/60941/psn-pdf
September 23, 2020 - Wrong-patient ordering errors in peripartum mother-
newborn pairs: a unique patient-safety challenge in
obstetrics.
September 23, 2020
Kern-Goldberger AR, Adelman JS, Applebaum JR, et al. Wrong-patient ordering errors in peripartum
mother-newborn pairs: a unique patient-safety challenge in obstetrics. Obstet Gynec…
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psnet.ahrq.gov/node/60947/psn-pdf
September 23, 2020 - FDA Advise-ERR: reported medication errors with Veklury
(remdesivir) emergency use authorization.
September 23, 2020
ISMP Medication Safety Alert! Acute care edition. September 10, 2020;25(18)
https://psnet.ahrq.gov/issue/fda-advise-err-reported-medication-errors-veklury-remdesivir-emergency-use-
authorizatio…
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psnet.ahrq.gov/node/34796/psn-pdf
November 18, 2015 - The business case for quality: case studies and an
analysis.
November 18, 2015
Leatherman S, Berwick DM, Iles D, et al. The business case for quality: case studies and an analysis.
Health Aff (Millwood). 2003;22(2):17-30.
https://psnet.ahrq.gov/issue/business-case-quality-case-studies-and-analysis
This comprehens…
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psnet.ahrq.gov/node/37430/psn-pdf
February 01, 2011 - Nonpayment for harms resulting from medical care:
catheter-associated urinary tract infections.
February 1, 2011
Wald HL, Kramer AM. Nonpayment for harms resulting from medical care: catheter-associated urinary tract
infections. JAMA. 2007;298(23):2782-4. doi:10.1001/jama.298.23.2782.
https://psnet.ahrq.gov/issue/…