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psnet.ahrq.gov/issue/organisational-learning-hospitals-concept-analysis
August 21, 2019 - Review
Organisational learning in hospitals: a concept analysis.
Citation Text:
Lyman B, Hammond EL, Cox JR. Organisational learning in hospitals: A concept analysis. J Nurs Manag. 2019;27(3):633-646. doi:10.1111/jonm.12722.
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DOI Google Scholar PubMed B…
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psnet.ahrq.gov/issue/redesigning-hospital-alarms-patient-safety-alarmed-and-potentially-dangerous
December 12, 2018 - Commentary
Redesigning hospital alarms for patient safety: alarmed and potentially dangerous.
Citation Text:
Chopra V, McMahon LF. Redesigning hospital alarms for patient safety: alarmed and potentially dangerous. JAMA. 2014;311(12):1199-200. doi:10.1001/jama.2014.710.
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psnet.ahrq.gov/issue/effects-mental-demands-during-dispensing-perceived-medication-safety-and-employee-well-being
May 16, 2012 - Study
Effects of mental demands during dispensing on perceived medication safety and employee well-being: a study of workload in pediatric hospital pharmacies.
Citation Text:
Holden RJ, Patel NR, Scanlon M, et al. Effects of mental demands during dispensing on perceived medication safe…
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psnet.ahrq.gov/issue/improving-accuracy-patient-identification-medication-use-process
May 09, 2014 - Commentary
Improving the accuracy of patient identification in the medication-use process.
Citation Text:
Trapskin PJ, White L, Armitstead JA. Improving the accuracy of patient identification in the medication-use process. Am J Health Syst Pharm. 2006;63(3):218, 220-2.
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psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-improving-safety-iv-drug-administration
March 23, 2012 - Study
Use of failure mode and effects analysis in improving the safety of i.v. drug administration.
Citation Text:
Adachi W, Lodolce AE. Use of failure mode and effects analysis in improving the safety of i.v. drug administration. Am J Health Syst Pharm. 2005;62(9):917-20.
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psnet.ahrq.gov/issue/interventions-improve-teamwork-and-communications-among-healthcare-staff
March 03, 2011 - Review
Interventions to improve teamwork and communications among healthcare staff.
Citation Text:
McCulloch P, Rathbone J, Catchpole K. Interventions to improve teamwork and communications among healthcare staff. Br J Surg. 2011;98(4):469-79. doi:10.1002/bjs.7434.
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psnet.ahrq.gov/issue/enhancing-effectiveness-team-debriefings-medical-simulation-more-best-practices
March 17, 2021 - Commentary
Enhancing the effectiveness of team debriefings in medical simulation: more best practices.
Citation Text:
Lyons R, Lazzara EH, Benishek LE, et al. Enhancing the effectiveness of team debriefings in medical simulation: more best practices. Jt Comm J Qual Patient Saf. 2015;41(3…
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psnet.ahrq.gov/issue/effect-hospital-command-centre-patient-safety-interrupted-time-series-study
July 20, 2022 - Study
Effect of a hospital command centre on patient safety: an interrupted time series study.
Citation Text:
Effect of a hospital command centre on patient safety: an interrupted time series study. Mebrahtu TF, McInerney CD, Benn J, et al. BMJ Health Care Inform. 2023;30(1):e100653…
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psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
September 01, 2015 - Good Night's Sleep Gone Wrong
Citation Text:
Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/49863/psn-pdf
May 01, 2019 - Good Catch in the Operating Room
May 1, 2019
Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/good-catch-operating-room
The Case
A 46-year-old woman with extensive history of back pain from lumbar stenosis was scheduled for an
elective laminectomy and spinal…
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psnet.ahrq.gov/node/861838/psn-pdf
January 31, 2024 - Adverse Drug Event (ADE) Surveillance and Pharmacist
Counseling
January 31, 2024
https://psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
Summary
Adverse events resulting from medications are a common occurrence that often go undetected, unreported,
and unaddressed.1 The imp…
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psnet.ahrq.gov/node/33824/psn-pdf
January 01, 2016 - Patient Safety and Opioid Medications
January 1, 2016
Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
Annual Perspective 2016
Opioid medications confer significant risks of harm, including overdose death …
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psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
March 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events
Citation Text:
Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Fo…
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psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety
September 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety
Citation Text:
Fatigue, Sleep Deprivation, and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/45890/psn-pdf
February 15, 2017 - A Framework for Safe, Reliable, and Effective Care.
February 15, 2017
Frankel A, Haraden C, Federico F, Lenoci-Edwards J. Cambridge, MA: Institute for Healthcare
Improvement and Safe & Reliable Healthcare; 2017.
https://psnet.ahrq.gov/issue/framework-safe-reliable-and-effective-care
A systems approach to safety ca…
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psnet.ahrq.gov/node/43282/psn-pdf
April 25, 2016 - Understanding the effect of resident duty hour reform: a
qualitative study.
April 25, 2016
Pattani R, Wu PE, Dhalla IA. Resident duty hours in Canada: past, present and future. Can Med Assoc J.
2014;186(10). doi:10.1503/cmaj.131053.
https://psnet.ahrq.gov/issue/understanding-effect-resident-duty-hour-reform-qualit…
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psnet.ahrq.gov/node/72632/psn-pdf
January 13, 2021 - Algorithmic prediction of failure modes in healthcare.
January 13, 2021
Kobo-Greenhut A, Sharlin O, Adler Y, et al. Algorithmic prediction of failure modes in healthcare. Int J Qual
Health Care. 2021;33(1):mzaa151. doi:10.1093/intqhc/mzaa151.
https://psnet.ahrq.gov/issue/algorithmic-prediction-failure-modes-healthc…
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psnet.ahrq.gov/node/848044/psn-pdf
April 26, 2023 - Effect of a hospital command centre on patient safety: an
interrupted time series study.
April 26, 2023
Mebrahtu TF, McInerney CD, Benn J, et al. BMJ Health Care Inform. 2023;30(1):e100653.
https://psnet.ahrq.gov/issue/effect-hospital-command-centre-patient-safety-interrupted-time-series-study
Command centers…
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psnet.ahrq.gov/node/60187/psn-pdf
April 01, 2020 - What are we doing when we double check?
April 1, 2020
Pfeiffer Y, Zimmermann C, Schwappach DLB. What are we doing when we double check? BMJ Qual Saf.
2020;29(7):536-540. doi:10.1136/bmjqs-2019-009680.
https://psnet.ahrq.gov/issue/what-are-we-doing-when-we-double-check
Double checking is one strategy for detecting …
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psnet.ahrq.gov/node/47795/psn-pdf
February 20, 2019 - Three laws for paperlessness.
February 20, 2019
Thimbleby H. Three laws for paperlessness. Digit Health. 2019;5:2055207619827722.
doi:10.1177/2055207619827722.
https://psnet.ahrq.gov/issue/three-laws-paperlessness
The digitization of health care data has had some positive effects on patient safety, but it has also…