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psnet.ahrq.gov/issue/what-extent-world-health-organizations-medication-safety-challenge-being-addressed-english
November 02, 2022 - Study
To what extent is the World Health Organization's Medication Safety Challenge being addressed in English hospital organizations? A descriptive study.
Citation Text:
Garfield S, Teo V, Chan L, et al. To what extent is the World Health Organization's Medication Safety Challenge being…
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psnet.ahrq.gov/issue/associations-between-internet-based-patient-ratings-and-conventional-surveys-patient
August 26, 2020 - Study
Associations between internet-based patient ratings and conventional surveys of patient experience in the English NHS: an observational study.
Citation Text:
Greaves F, Pape UJ, King D, et al. Associations between Internet-based patient ratings and conventional surveys of patient…
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psnet.ahrq.gov/issue/how-do-patients-respond-safety-problems-ambulatory-care-results-retrospective-cross-sectional
September 15, 2021 - Study
How do patients respond to safety problems in ambulatory care? Results of a retrospective cross-sectional telephone survey.
Citation Text:
Seufert S, de Cruppé W, Assheuer M, et al. How do patients respond to safety problems in ambulatory care? Results of a retrospective cross-sect…
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psnet.ahrq.gov/issue/analysis-prehospital-pediatric-medication-dosing-errors-after-implementation-state-wide-ems
August 25, 2021 - Study
An analysis of prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference.
Citation Text:
Kazi R, Hoyle JD, Huffman C, et al. An analysis of prehospital pediatric medication dosing errors after implementation of a state-w…
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psnet.ahrq.gov/issue/evaluating-independent-double-checks-pediatric-intensive-care-unit-human-factors-engineering
October 07, 2013 - Study
Evaluating independent double checks in the pediatric intensive care unit: a human factors engineering approach.
Citation Text:
Konwinski L, Steenland C, Miller K, et al. Evaluating independent double checks in the pediatric intensive care unit: a human factors engineering approach…
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psnet.ahrq.gov/issue/identifying-adverse-events-patients-hospitalized-isolation-or-quarantine-due-covid-19
September 13, 2023 - Study
Identifying adverse events in patients hospitalized in isolation or quarantine due to COVID-19.
Citation Text:
de Arriba Fernández A, Sánchez Medina R, Dorta Hung ME, et al. Identifying adverse events in patients hospitalized in isolation or quarantine due to COVID-19. J Patient Sa…
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psnet.ahrq.gov/issue/burnout-and-sources-stress-among-health-care-risk-managers-and-patient-safety-personnel
May 26, 2021 - Study
Burnout and sources of stress among health care risk managers and patient safety personnel during the COVID-19 pandemic: a pilot study.
Citation Text:
Card AJ. Burnout and sources of stress among health care risk managers and patient safety personnel during the COVID-19 pandemic: a…
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psnet.ahrq.gov/issue/effects-rudeness-experience-and-perspective-taking-challenging-premature-closure-after
February 16, 2022 - Study
The effects of rudeness, experience, and perspective-taking on challenging premature closure after pediatric ICU physicians receive hand-off with the wrong diagnosis: a randomized controlled simulation trial.
Citation Text:
Avesar M, Erez A, Essakow J, et al. The effects of rudenes…
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psnet.ahrq.gov/issue/clinical-triggers-alternative-rapid-response-team
December 21, 2014 - Study
Clinical triggers: an alternative to a rapid response team.
Citation Text:
Moldenhauer K, Sabel A, Chu ES, et al. Clinical triggers: an alternative to a rapid response team. Jt Comm J Qual Patient Saf. 2009;35(3):164-74.
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psnet.ahrq.gov/issue/locating-errors-through-networked-surveillance-multimethod-approach-peer-assessment-hazard
May 24, 2012 - Study
Locating errors through networked surveillance: a multimethod approach to peer assessment, hazard identification, and prioritization of patient safety efforts in cardiac surgery.
Citation Text:
Thompson DA, Marsteller JA, Pronovost P, et al. Locating Errors Through Networked Survei…
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psnet.ahrq.gov/issue/patient-safety-recommendations-covid-19-epidemic-outbreak-lessons-italian-experience
February 15, 2023 - Book/Report
Patient Safety Recommendations for COVID-19 Epidemic Outbreak: 3.0
Citation Text:
Patient Safety Recommendations for COVID-19 Epidemic Outbreak: 3.0 La Regina M, Tanzini M, Venneri F, et al for the Italian Network for Health Safety. Dublin, Ireland: International Society for …
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psnet.ahrq.gov/node/33745/psn-pdf
February 01, 2013 - Patient Engagement and Patient Safety
February 1, 2013
Weingart SN. Patient Engagement and Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
Perspective
Patient engagement has arrived at the station. A Google search of this phrase identified 335,000 hi…
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psnet.ahrq.gov/node/49836/psn-pdf
July 01, 2018 - Primary Workaround, Secondary Complication
July 1, 2018
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
The Case
A young adult with a progressive neurological disorder presented to a hospital emerg…
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - Diffusion of Responsibility Leads to Danger
October 1, 2018
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
The Case
A 70-year-old man was sent to the emergency department (ED) from a nursing facility…
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psnet.ahrq.gov/node/33629/psn-pdf
March 01, 2006 - What Does Simulation Add to Teamwork Training?
March 1, 2006
Gaba DM. What Does Simulation Add to Teamwork Training? PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/what-does-simulation-add-teamwork-training
Editor's Note: In these point–counterpoint articles, Drs. Pratt and Sachs of Beth Israel Deacones…
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psnet.ahrq.gov/web-mm/cups-error
January 12, 2011 - Cups of Error
Citation Text:
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/840255/psn-pdf
November 16, 2022 - Using Human Factors Engineering and the SEIPS Model
to Advance Patient Safety in Care Transitions
November 16, 2022
Carayon P, Werner N, Makkenchery A, et al. Using Human Factors Engineering and the SEIPS Model to
Advance Patient Safety in Care Transitions . PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspecti…
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psnet.ahrq.gov/node/853080/psn-pdf
August 30, 2023 - Virtual Nursing: Improving Patient Care and Meeting
Workforce Challenges
August 30, 2023
Sanford K, Schuelke S, Lee M, et al. Virtual Nursing: Improving Patient Care and Meeting Workforce
Challenges. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workf…
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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psnet.ahrq.gov/node/841493/psn-pdf
December 14, 2022 - Telehealth and Patient Safety.
December 14, 2022
O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/telehealth-and-patient-safety
Background
In recent years, telehealth, or the delivery of healthcare over a distance using telecommunications
techno…