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psnet.ahrq.gov/node/37467/psn-pdf
January 01, 2009 - Costs of intravenous adverse drug events in academic
and nonacademic intensive care units.
January 16, 2008
Nuckols TK, Paddock SM, Bower AG, et al. Costs of intravenous adverse drug events in academic and
nonacademic intensive care units. Med Care. 2009;46(1):17-24. doi:10.1097/mlr.0b013e3181589bed.
https://psnet…
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psnet.ahrq.gov/node/50945/psn-pdf
February 26, 2020 - She hoped to shine a light on maternal mortality among
Native Americans. Instead, she became a statistic of it.
February 26, 2020
Chuck E, Assefa H. NBC News. February 8, 2020.
https://psnet.ahrq.gov/issue/she-hoped-shine-light-maternal-mortality-among-native-americans-instead-
she-became-statistic
Maternal morbi…
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psnet.ahrq.gov/node/43878/psn-pdf
February 04, 2015 - Mandatory reporting of impaired medical practitioners:
protecting patients, supporting practitioners.
February 4, 2015
Bismark MM, Morris JM, Clarke C. Mandatory reporting of impaired medical practitioners: protecting
patients, supporting practitioners. Intern Med J. 2014;44(12a):1165-9. doi:10.1111/imj.12613.
htt…
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psnet.ahrq.gov/node/866117/psn-pdf
January 01, 2025 - Diagnostic disparities and strategies for enhancing
diagnostic equity in hospital medicine.
June 12, 2024
Raffel KE, Gershanik EF, Ranji SR. Diagnostic disparities and strategies for enhancing diagnostic equity in
hospital medicine. J Hosp Med. 2025;20(1):71-74. doi:10.1002/jhm.13375.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/47776/psn-pdf
August 20, 2021 - FDA Safety Communication: update--robotically-assisted
surgical devices in mastectomy.
August 20, 2021
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.
https://psnet.ahrq.gov/issue/fda-safety-communication-caution-when-using-robotically-assisted-surgical-
devices-womens
…
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psnet.ahrq.gov/node/40645/psn-pdf
November 26, 2012 - Rapid-response teams.
November 26, 2012
Jones D, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med. 2011;365(2):139-46.
doi:10.1056/NEJMra0910926.
https://psnet.ahrq.gov/issue/rapid-response-teams
Delays in clinical deterioration recognition and failures to rescue lead to serious adverse events. Rapid
resp…
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psnet.ahrq.gov/node/45096/psn-pdf
May 05, 2016 - Patient safety at the crossroads.
May 5, 2016
Gandhi TK, Berwick DM, Shojania KG. Patient Safety at the Crossroads. JAMA. 2016;315(17):1829-30.
doi:10.1001/jama.2016.1759.
https://psnet.ahrq.gov/issue/patient-safety-crossroads
This commentary discusses findings from the National Patient Safety Foundation report in…
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psnet.ahrq.gov/node/35451/psn-pdf
January 05, 2017 - Closing the loop: follow-up and feedback in a patient
safety program.
January 5, 2017
Gandhi TK, Graydon-Baker E, Huber CN, et al. Closing the loop: follow-up and feedback in a patient safety
program. Jt Comm J Qual Patient Saf. 2005;31(11):614-21.
https://psnet.ahrq.gov/issue/closing-loop-follow-and-feedback-pati…
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psnet.ahrq.gov/node/73163/psn-pdf
April 21, 2021 - Implicit bias in healthcare: clinical practice, research and
decision making.
April 21, 2021
Gopal DP, Chetty U, O'Donnell P, et al. Implicit bias in healthcare: clinical practice, research and decision
making. Future Healthc J. 2021;8(1):40-48. doi:10.7861/fhj.2020-0233.
https://psnet.ahrq.gov/issue/implicit-bias…
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psnet.ahrq.gov/node/37487/psn-pdf
May 26, 2011 - Predicting computerized physician order entry system
adoption in US hospitals: can the federal mandate be
met?
May 26, 2011
Ford EW, McAlearney AS, Phillips MT, et al. Predicting computerized physician order entry system
adoption in US hospitals: Can the federal mandate be met? Int J Med Inform. 2007;77(8).
doi:1…
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psnet.ahrq.gov/node/35404/psn-pdf
March 11, 2011 - Improving patient safety by identifying side effects from
introducing bar coding in medication administration.
March 11, 2011
Patterson ES, Cook RI, Render ML. Improving patient safety by identifying side effects from introducing bar
coding in medication administration. J Am Med Inform Assoc. 2002;9(5):540-53.
htt…
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February 25, 2015 - Application of the aviation black box principle in pediatric
cardiac surgery: tracking all failures in the pediatric
cardiac operating room.
February 25, 2015
Bowermaster R, Miller M, Ashcraft T, et al. Application of the aviation black box principle in pediatric
cardiac surgery: tracking all failures in the pedia…
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psnet.ahrq.gov/node/38334/psn-pdf
January 14, 2009 - Adverse Events in Hospitals: State Reporting Systems.
January 14, 2009
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector
General; December 2008. Report No. OEI-06-07-00471.
https://psnet.ahrq.gov/issue/adverse-events-hospitals-state-reporting-systems
The Tax Relief an…
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psnet.ahrq.gov/node/46690/psn-pdf
December 20, 2017 - Quality, safety, and outcomes in anaesthesia: what's to be
done? An international perspective.
December 20, 2017
Peden CJ, Campbell M, Aggarwal G. Quality, safety, and outcomes in anaesthesia: what's to be done? An
international perspective. Br J Anaesth. 2017;119. doi:10.1093/bja/aex346.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/60536/psn-pdf
May 27, 2020 - Nursing home workers warned government about safety
violations before COVID-19 outbreaks and deaths.
May 27, 2020
Ellis B, Hicken M. CNN. May 14, 2020.
https://psnet.ahrq.gov/issue/nursing-home-workers-warned-government-about-safety-violations-covid-19-
outbreaks-and-deaths
Long-term care and skilled nursing faci…
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psnet.ahrq.gov/node/44669/psn-pdf
January 22, 2016 - Safety standards: implementing fall prevention
interventions and sustaining lower fall rates by promoting
the culture of safety on an inpatient rehabilitation unit.
January 22, 2016
Leone RM, Adams RJ. Safety Standards: Implementing Fall Prevention Interventions and Sustaining Lower
Fall Rates by Promoting the Cul…
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psnet.ahrq.gov/node/46017/psn-pdf
July 11, 2017 - Challenging hierarchy in healthcare teams--ways to
flatten gradients to improve teamwork and patient care.
July 11, 2017
Green B, Oeppen RS, Smith DW, et al. Challenging hierarchy in healthcare teams - ways to flatten
gradients to improve teamwork and patient care. Br J Oral Maxillofac Surg. 2017;55(5):449-453.
do…
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psnet.ahrq.gov/node/837672/psn-pdf
July 13, 2022 - Optimizing post-acute care patient safety: a scoping
review of multifactorial fall prevention interventions for
older adults.
July 13, 2022
Leland NE, Lekovitch C, Martínez J, et al. Optimizing post-acute care patient safety: a scoping review of
multifactorial fall prevention interventions for older adults. J Appl…
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psnet.ahrq.gov/node/35516/psn-pdf
February 03, 2011 - Supplemental perioperative oxygen and the risk of
surgical wound infection: a randomized controlled trial.
February 3, 2011
Belda J, Aguilera L, de la Asunción JG, et al. Supplemental perioperative oxygen and the risk of surgical
wound infection: a randomized controlled trial. JAMA. 2005;294(16):2035-42.
https://p…
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psnet.ahrq.gov/node/47980/psn-pdf
May 01, 2019 - Intensive care medicine in 2050: preventing harm.
May 1, 2019
Beet C, Benoit D, Bion J. Intensive care medicine in 2050: preventing harm. Intensive Care Med.
2019;45(4):505-507. doi:10.1007/s00134-018-5353-z.
https://psnet.ahrq.gov/issue/intensive-care-medicine-2050-preventing-harm
This commentary discusses curren…