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psnet.ahrq.gov/node/38621/psn-pdf
February 18, 2011 - Process of care failures in breast cancer diagnosis.
February 18, 2011
Weingart SN, Saadeh MG, Simchowitz B, et al. Process of care failures in breast cancer diagnosis. J Gen
Intern Med. 2009;24(6):702-709. doi:10.1007/s11606-009-0982-0.
https://psnet.ahrq.gov/issue/process-care-failures-breast-cancer-diagnosis
Di…
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psnet.ahrq.gov/node/43401/psn-pdf
August 02, 2015 - Morning handover of on-call issues: opportunities for
improvement.
August 2, 2015
Devlin MK, Kozij NK, Kiss A, et al. Morning handover of on-call issues: opportunities for improvement.
JAMA Intern Med. 2014;174(9):1479-85. doi:10.1001/jamainternmed.2014.3033.
https://psnet.ahrq.gov/issue/morning-handover-call-issu…
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psnet.ahrq.gov/node/39063/psn-pdf
December 17, 2009 - Safety and risk management interventions in hospitals: a
systematic review of the literature.
December 17, 2009
Dückers M, Faber M, Cruijsberg J, et al. Safety and risk management interventions in hospitals: a
systematic review of the literature. Med Care Res Rev. 2009;66(6 Suppl):90S-119S.
doi:10.1177/10775587093…
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psnet.ahrq.gov/node/44683/psn-pdf
June 21, 2016 - Physician spending and subsequent risk of malpractice
claims: observational study.
June 21, 2016
Jena AB, Schoemaker L, Bhattacharya J, et al. Physician spending and subsequent risk of malpractice
claims: observational study. BMJ. 2015;351:h5516. doi:10.1136/bmj.h5516.
https://psnet.ahrq.gov/issue/physician-spendi…
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psnet.ahrq.gov/node/43176/psn-pdf
July 03, 2014 - Patient safety in the era of the 80-hour workweek.
July 3, 2014
Shelton J, Kummerow K, Phillips S, et al. Patient safety in the era of the 80-hour workweek. J Surg Educ.
2014;71(4):551-9. doi:10.1016/j.jsurg.2013.12.011.
https://psnet.ahrq.gov/issue/patient-safety-era-80-hour-workweek
Regulations intended to reduc…
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psnet.ahrq.gov/node/45375/psn-pdf
September 27, 2016 - Association of a web-based handoff tool with rates of
medical errors.
September 27, 2016
Mueller SK, Yoon CS, Schnipper JL. Association of a Web-Based Handoff Tool With Rates of Medical
Errors. JAMA Intern Med. 2016;176(9):1400-2. doi:10.1001/jamainternmed.2016.4258.
https://psnet.ahrq.gov/issue/association-web-ba…
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psnet.ahrq.gov/node/45509/psn-pdf
September 28, 2016 - Computerized triggers of big data to detect delays in
follow-up of chest imaging results.
September 28, 2016
Murphy DR, Meyer AND, Bhise V, et al. Computerized Triggers of Big Data to Detect Delays in Follow-up
of Chest Imaging Results. Chest. 2016;150(3):613-20. doi:10.1016/j.chest.2016.05.001.
https://psnet.ahrq…
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psnet.ahrq.gov/node/48150/psn-pdf
August 21, 2019 - Communication between primary and secondary care:
deficits and danger.
August 21, 2019
Dinsdale E, Hannigan A, O’Connor R, et al. Communication between primary and secondary care: deficits
and danger. Fam Pract. 2019;17(1):63-68. doi:10.1093/fampra/cmz037.
https://psnet.ahrq.gov/issue/communication-between-primary…
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psnet.ahrq.gov/node/43174/psn-pdf
December 12, 2014 - Adverse drug event detection in pediatric oncology and
hematology patients: using medication triggers to identify
patient harm in a specialized pediatric patient population.
December 12, 2014
Call RJ, Burlison JD, Robertson JJ, et al. Adverse drug event detection in pediatric oncology and
hematology patients: usin…
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psnet.ahrq.gov/node/47063/psn-pdf
November 19, 2018 - I-PASS handoff program: use of a campaign to effect
transformational change.
November 19, 2018
Rosenbluth G, Destino LA, Starmer AJ, et al. I-PASS Handoff Program: Use of a Campaign to Effect
Transformational Change. Ped Qual Saf. 2018;3(4):e088. doi:10.1097/pq9.0000000000000088.
https://psnet.ahrq.gov/issue/i-pas…
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psnet.ahrq.gov/node/39294/psn-pdf
January 03, 2017 - Patient handoffs: standardized and reliable measurement
tools remain elusive.
January 3, 2017
Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Jt
Comm J Qual Patient Saf. 2010;36(2):52-61.
https://psnet.ahrq.gov/issue/patient-handoffs-standardized-and-reliable-m…
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psnet.ahrq.gov/node/46560/psn-pdf
January 24, 2019 - The hidden cost of regulation: the administrative cost of
reporting serious reportable events.
January 24, 2019
Blanchfield BB, Acharya B, Mort E. The Hidden Cost of Regulation: The Administrative Cost of Reporting
Serious Reportable Events. Jt Comm J Qual Patient Saf. 2018;44(4):212-218.
doi:10.1016/j.jcjq.2017.0…
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psnet.ahrq.gov/node/40236/psn-pdf
March 23, 2012 - The safety implications of missed test results for
hospitalised patients: a systematic review.
March 23, 2012
Callen J, Georgiou A, Li J, et al. The safety implications of missed test results for hospitalised patients: a
systematic review. BMJ Qual Saf. 2011;20(2):194-199. doi:10.1136/bmjqs.2010.044339.
https://ps…
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psnet.ahrq.gov/node/44542/psn-pdf
December 22, 2018 - The prevalence of medical error related to end-of-life
communication in Canadian hospitals: results of a
multicentre observational study.
December 22, 2018
Heyland DK, Ilan R, Jiang X, et al. The prevalence of medical error related to end-of-life communication in
Canadian hospitals: results of a multicentre observ…
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psnet.ahrq.gov/node/41775/psn-pdf
December 18, 2014 - Measuring adverse events and levels of harm in pediatric
inpatients with the Global Trigger Tool.
December 18, 2014
Kirkendall E, Kloppenborg E, Papp J, et al. Measuring adverse events and levels of harm in pediatric
inpatients with the Global Trigger Tool. Pediatrics. 2012;130(5):e1206-14. doi:10.1542/peds.2012-01…
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psnet.ahrq.gov/node/43308/psn-pdf
May 01, 2015 - An analysis of electronic health record–related patient
safety concerns.
May 1, 2015
Meeks DW, Smith MW, Taylor L, et al. An analysis of electronic health record-related patient safety
concerns. J Am Med Inform Assoc. 2014;21(6):1053-9. doi:10.1136/amiajnl-2013-002578.
https://psnet.ahrq.gov/issue/analysis-electro…
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psnet.ahrq.gov/node/45101/psn-pdf
July 01, 2017 - A systematic review of patient safety measures in adult
primary care.
July 1, 2017
Hatoun J, Chan J, Yaksic E, et al. A Systematic Review of Patient Safety Measures in Adult Primary Care.
Am J Med Qual. 2017;32(3):237-245. doi:10.1177/1062860616644328.
https://psnet.ahrq.gov/issue/systematic-review-patient-safety-…
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psnet.ahrq.gov/node/45955/psn-pdf
January 01, 2021 - The essential role of leadership in developing a safety
culture.
April 3, 2017
The essential role of leadership in developing a safety culture. Sentinel Event Alert. 2021;57(57):1-8.
https://psnet.ahrq.gov/issue/essential-role-leadership-developing-safety-culture
The Joint Commission issues sentinel event alerts t…
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psnet.ahrq.gov/node/46807/psn-pdf
July 02, 2019 - Communication failure: analysis of prescribers' use of an
internal free-text field on electronic prescriptions.
July 2, 2019
Ai A, Wong A, Amato MG, et al. Communication failure: analysis of prescribers’ use of an internal free-text
field on electronic prescriptions. J Am Med Inform Assoc. 2018;25(6):709-714. doi:1…
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psnet.ahrq.gov/node/44560/psn-pdf
January 23, 2017 - What is the return on investment for implementation of a
crew resource management program at an academic
medical center?
January 23, 2017
Moffatt-Bruce SD, Hefner JL, Mekhjian H, et al. What Is the Return on Investment for Implementation of a
Crew Resource Management Program at an Academic Medical Center? Am J Med…