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psnet.ahrq.gov/node/60617/psn-pdf
June 24, 2020 - Amid the COVID-19 pandemic, meaningful communication
between family caregivers and residents of long-term care
facilities is imperative.
June 24, 2020
Hado E, Friss Feinberg L. Amid the COVID-19 pandemic, meaningful communication between family
caregivers and residents of long-term care facilities is imperative. J…
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psnet.ahrq.gov/node/44872/psn-pdf
February 12, 2016 - Reducing preventable harm in hospitals.
February 12, 2016
Bornstein D. New York Times. January 26, and February 2, 2016.
https://psnet.ahrq.gov/issue/reducing-preventable-harm-hospitals
Discussing the importance of designing safeguards to prevent system failures that can result in patient
harm, this two-part newsp…
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psnet.ahrq.gov/node/35635/psn-pdf
June 24, 2010 - Patient safety problems in adolescent medical care.
June 24, 2010
Woods D, Holl JL, Klein JD, et al. Patient safety problems in adolescent medical care. J Adolesc Health.
2006;38(1):5-12.
https://psnet.ahrq.gov/issue/patient-safety-problems-adolescent-medical-care
Using data from the Colorado and Utah Medical Prac…
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psnet.ahrq.gov/node/44512/psn-pdf
September 23, 2015 - Increased mortality associated with weekend hospital
admission: a case for expanded seven day services?
September 23, 2015
Freemantle N, Ray D, McNulty D, et al. Increased mortality associated with weekend hospital admission: a
case for expanded seven day services? BMJ. 2015;351:h4596. doi:10.1136/bmj.h4596.
https…
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psnet.ahrq.gov/node/45546/psn-pdf
October 05, 2016 - Using standardized OR checklists and creating extended
time-out checklists.
October 5, 2016
Hey LA, Turner TC. Using Standardized OR Checklists and Creating Extended Time-Out Checklists.
AORN J. 2016;104(3):248-53. doi:10.1016/j.aorn.2016.07.007.
https://psnet.ahrq.gov/issue/using-standardized-or-checklists-and-cr…
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psnet.ahrq.gov/node/72723/psn-pdf
February 10, 2021 - The impact of critical incidents on nurses and midwives:
a systematic review.
February 10, 2021
Buhlmann M, Ewens B, Rashidi A. The impact of critical incidents on nurses and midwives: A systematic
review. J Clin Nurs. 2020;30(9-10):1195-1205. doi:10.1111/jocn.15608.
https://psnet.ahrq.gov/issue/impact-critical-in…
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psnet.ahrq.gov/node/36558/psn-pdf
May 27, 2011 - The National Quality Forum safe practice standard for
computerized physician order entry: updating a critical
patient safety practice.
May 27, 2011
Kilbridge PM, Classen D, Bates DW, et al. The National Quality Forum Safe Practice Standard for
Computerized Physician Order Entry. J Patient Saf. 2008;2(4). doi:10.10…
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psnet.ahrq.gov/node/34812/psn-pdf
March 05, 2008 - The critical incident technique.
March 5, 2008
FLANAGAN JC. The critical incident technique. Psychol Bull. 1954;51(4):327-358.
https://psnet.ahrq.gov/issue/critical-incident-technique
This review details the background of a methodology aimed to record specific behaviors, rather than
opinions or estimates, in evalu…
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psnet.ahrq.gov/node/46503/psn-pdf
January 31, 2018 - Clinical decision-making: heuristics and cognitive biases
for the ophthalmologist.
January 31, 2018
Hussain A, Oestreicher J. Clinical decision-making: heuristics and cognitive biases for the ophthalmologist.
Surv Ophthalmol. 2018;63(1):119-124. doi:10.1016/j.survophthal.2017.08.007.
https://psnet.ahrq.gov/issue/c…
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psnet.ahrq.gov/node/43971/psn-pdf
April 25, 2016 - Why empathy may be the best risk management strategy.
April 25, 2016
Hertz BT. Why empathy may be the best risk management strategy. Medical economics. 2015;92(3):40-4.
https://psnet.ahrq.gov/issue/why-empathy-may-be-best-risk-management-strategy
Communication and response strategies have been shown to improve how …
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psnet.ahrq.gov/node/44521/psn-pdf
July 03, 2016 - Crib of horrors: one hospital's approach to promoting a
culture of safety.
July 3, 2016
Korah N, Zavalkoff S, Dubrovsky AS. Crib of Horrors: One Hospital's Approach to Promoting a Culture of
Safety. Pediatrics. 2015;136(1):4-5. doi:10.1542/peds.2014-3843.
https://psnet.ahrq.gov/issue/crib-horrors-one-hospitals-app…
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psnet.ahrq.gov/node/38241/psn-pdf
January 15, 2009 - In chronic condition: experiences of patients with
complex health care needs, in eight countries, 2008.
January 15, 2009
Schoen C, Osborn R, How SKH, et al. In chronic condition: experiences of patients with complex health
care needs, in eight countries, 2008. Health Aff (Millwood). 2009;28(1):w1-16. doi:10.1377/hl…
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psnet.ahrq.gov/node/36789/psn-pdf
June 16, 2008 - Promoting a culture of patient safety: a review of the
Florida moratoria data: what we have learned in 6 years
and the need for continued patient education.
June 16, 2008
Clayman MA, Clayman SM, Steele MH, et al. Promoting a culture of patient safety: a review of the Florida
moratoria data: what we have learned in…
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psnet.ahrq.gov/node/46348/psn-pdf
June 13, 2018 - The nexus of nursing leadership and a culture of safer
patient care.
June 13, 2018
Murray M, Sundin D, Cope V. The nexus of nursing leadership and a culture of safer patient care. J Clin
Nurs. 2018;27(5-6):1287-1293. doi:10.1111/jocn.13980.
https://psnet.ahrq.gov/issue/nexus-nursing-leadership-and-culture-safer-pa…
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psnet.ahrq.gov/node/35736/psn-pdf
May 27, 2011 - Video capture of clinical care to enhance patient safety.
May 27, 2011
Weinger MB, Gonzales DC, Slagle J, et al. Video capture of clinical care to enhance patient safety. Qual
Saf Health Care. 2004;13(2):136-44.
https://psnet.ahrq.gov/issue/video-capture-clinical-care-enhance-patient-safety
This study describes th…
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psnet.ahrq.gov/node/859353/psn-pdf
December 20, 2023 - Global State of Patient Safety 2023.
December 20, 2023
Illingworth J, Shaw A, Fernandez et al. London UK: Imperial College London; 2023.
https://psnet.ahrq.gov/issue/global-state-patient-safety-2023
Patient safety data can support learning health systems and worldwide improvement. This report discusses
a set of in…
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psnet.ahrq.gov/node/35417/psn-pdf
February 15, 2010 - Errors in laboratory medicine: practical lessons to
improve patient safety.
February 15, 2010
Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab
Med. 2005;129(10):1252-1261.
https://psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patie…
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psnet.ahrq.gov/node/60564/psn-pdf
June 03, 2020 - Subtherapeutic heparin infusions: is your organization at
risk of bypassing soft low-dose alerts?
June 3, 2020
ISMP Medication Safety Alert! Acute Care Edition. May 22, 2020;25(10).
https://psnet.ahrq.gov/issue/subtherapeutic-heparin-infusions-your-organization-risk-bypassing-soft-low-
dose-alerts
Smart infusion …
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psnet.ahrq.gov/node/47424/psn-pdf
November 21, 2018 - Creating a culture of accountability promotes safe
medical care.
November 21, 2018
Canadian Medical Protective Association; CMPA.
https://psnet.ahrq.gov/issue/creating-culture-accountability-promotes-safe-medical-care
Frontline leadership should model just culture behaviors to encourage reporting and discussion of…
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psnet.ahrq.gov/node/50423/psn-pdf
September 04, 2019 - When a vital sign leads a country astray—the opioid
epidemic.
September 4, 2019
Chidgey BA, McGinigle KL, McNaull PP. When a Vital Sign Leads a Country Astray—The Opioid Epidemic.
JAMA Surg. 2019;154(11):987-988. doi:10.1001/jamasurg.2019.2104.
https://psnet.ahrq.gov/issue/when-vital-sign-leads-country-astray-opio…