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psnet.ahrq.gov/node/48105/psn-pdf
July 10, 2019 - Teaching medical students to recognise and report
errors.
July 10, 2019
Mohsin SU, Ibrahim Y, Levine D. Teaching medical students to recognise and report errors. BMJ Open
Qual. 2019;8(2):e000558. doi:10.1136/bmjoq-2018-000558.
https://psnet.ahrq.gov/issue/teaching-medical-students-recognise-and-report-errors
This…
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psnet.ahrq.gov/node/43933/psn-pdf
March 04, 2015 - How informatics nurses use bar code technology to
reduce medication errors.
March 4, 2015
Gann M. How informatics nurses use bar code technology to reduce medication errors. Nursing (Brux).
2015;45(3):60-6. doi:10.1097/01.NURSE.0000458923.18468.37.
https://psnet.ahrq.gov/issue/how-informatics-nurses-use-bar-code-t…
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psnet.ahrq.gov/node/44716/psn-pdf
April 15, 2016 - An integrative review of patient safety in studies on the
care and safety of patients with communication
disabilities in hospital.
April 15, 2016
Hemsley B, Georgiou A, Hill S, et al. An integrative review of patient safety in studies on the care and
safety of patients with communication disabilities in hospital. …
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psnet.ahrq.gov/node/43311/psn-pdf
July 02, 2014 - Some IV medications are diluted unnecessarily in patient
care areas, creating undue risk.
July 2, 2014
ISMP Medication Safety Alert! Acute Care Edition. June 19, 2014;19:1-5.
https://psnet.ahrq.gov/issue/some-iv-medications-are-diluted-unnecessarily-patient-care-areas-creating-
undue-risk
This newsletter article …
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psnet.ahrq.gov/node/866408/psn-pdf
July 31, 2024 - Influences of leadership, organizational culture, and
hierarchy on raising concerns about patient deterioration:
a qualitative study.
July 31, 2024
Vehvilainen E, Charles A, Sainsbury J, et al. Influences of leadership, organizational culture, and hierarchy
on raising concerns about patient deterioration: a qualit…
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psnet.ahrq.gov/node/848089/psn-pdf
April 26, 2023 - Patient Safety Advisory: fentanyl counterfeit prescription
medications that contain fentanyl and patient safety.
April 26, 2023
Jewell ML, Jewell HL, Singer R, et al. Patient Safety Advisory: fentanyl counterfeit prescription medications
that contain fentanyl and patient safety. Aesthetic Plast Surg. 2023;47(3):123…
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psnet.ahrq.gov/node/47793/psn-pdf
June 12, 2019 - Can mindfulness in health care professionals improve
patient care? An integrative review and proposed model.
June 12, 2019
Braun SE, Kinser PA, Rybarczyk B. Can mindfulness in health care professionals improve patient care? An
integrative review and proposed model. Transl Behav Med. 2019;9(2):187-201. doi:10.1093/t…
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psnet.ahrq.gov/node/853073/psn-pdf
August 30, 2023 - Mind the power gap: how hierarchical leadership in
healthcare is a risk to patient safety.
August 30, 2023
Kanaris C. Mind the power gap: how hierarchical leadership in healthcare is a risk to patient safety. J Child
Health Care. 2023;27(3):319-322. doi:10.1177/13674935231196197.
https://psnet.ahrq.gov/issue/mind-…
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psnet.ahrq.gov/web-mm/failure-latch
November 27, 2012 - Failure to Latch
Citation Text:
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/node/860050/psn-pdf
January 04, 2024 - Radiology Missed an Intracranial Bleed in a Lethargic
Infant.
January 4, 2024
Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
The Case
A 2-month-old full-term male infant was b…
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psnet.ahrq.gov/node/47143/psn-pdf
January 30, 2019 - E-learning on risk management. An opportunity for
sharing knowledge and experiences in patient safety.
January 30, 2019
Agra Y, García-Álvarez V, Aibar-Remón C, et al. E-learning on risk management. An opportunity for
sharing knowledge and experiences in patient safety. Int J Health Care Qual. 2019;31(8):639-646.
…
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psnet.ahrq.gov/node/860385/psn-pdf
January 10, 2024 - Factors affecting medical residents' decisions to work
after call.
January 10, 2024
Carr MM, Foreman AM, Friedel JE, et al. Factors affecting medical residents' decisions to work after call. J
Patient Saf. 2024;20(1):16-21. doi:10.1097/pts.0000000000001175.
https://psnet.ahrq.gov/issue/factors-affecting-medical-re…
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psnet.ahrq.gov/node/74861/psn-pdf
February 23, 2022 - A concept analysis of psychological safety: further
understanding for application to health care.
February 23, 2022
Ito A, Sato K, Yumoto Y, et al. A concept analysis of psychological safety: further understanding for
application to health care. Nurs Open. 2021;9(1):467-489. doi:10.1002/nop2.1086.
https://psnet.ah…
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psnet.ahrq.gov/node/45578/psn-pdf
January 23, 2017 - S-TEAMS: a truly multiprofessional course focusing on
nontechnical skills to improve patient safety in the
operating theater.
January 23, 2017
Stewart-Parker E, Galloway R, Vig S. S-TEAMS: A Truly Multiprofessional Course Focusing on
Nontechnical Skills to Improve Patient Safety in the Operating Theater. J Surg Ed…
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psnet.ahrq.gov/node/45920/psn-pdf
May 05, 2017 - Examining the nature of interprofessional interventions
designed to promote patient safety: a narrative review.
May 5, 2017
Reeves ST, Clark E, Lawton S, et al. Examining the nature of interprofessional interventions designed to
promote patient safety: a narrative review. International Journal for Quality in Health…
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psnet.ahrq.gov/node/863222/psn-pdf
February 28, 2024 - Systematic review of morbidity and mortality meeting
standardization: does it lead to improved professional
development, system improvements, clinician
engagement, and enhanced patient safety culture?
February 28, 2024
Steel EJ, Janda M, Jamali S, et al. Systematic review of morbidity and mortality meeting standar…
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psnet.ahrq.gov/node/836773/psn-pdf
March 23, 2022 - Association between operative autonomy of surgical
residents and patient outcomes.
March 23, 2022
Oliver JB, Kunac A, McFarlane JL, et al. Association between operative autonomy of surgical residents and
patient outcomes. JAMA Surg. 2022;157(3):211-219. doi:10.1001/jamasurg.2021.6444.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/46291/psn-pdf
July 26, 2017 - Experiences with Lean Six Sigma as improvement
strategy to reduce parenteral medication administration
errors and associated potential risk of harm.
July 26, 2017
van de Plas A, Slikkerveer M, Hoen S, et al. Experiences with Lean Six Sigma as improvement strategy to
reduce parenteral medication administration erro…
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psnet.ahrq.gov/node/867180/psn-pdf
November 20, 2024 - Medical error: using storytelling and reflection to impact
error response factors in family medicine residents.
November 20, 2024
Adkins S, Alta’any R, Brar K, et al. Medical error: using storytelling and reflection to impact error response
factors in family medicine residents. J Med Educ Curric Dev. 2024;11:238212…
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psnet.ahrq.gov/node/848038/psn-pdf
April 26, 2023 - Assessing system thinking in senior pharmacy students
using the innovative "Horror Room" simulation setting: a
cross-sectional survey of a non-technical skill.
April 26, 2023
Aljuffali LA, Almalag HM, Alnaim L. Assessing system thinking in senior pharmacy students using the
innovative "Horror Room" simulation sett…