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psnet.ahrq.gov/node/46438/psn-pdf
September 20, 2017 - Communicating Clearly About Medicines: Proceedings of
a Workshop.
September 20, 2017
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies
Press: 2017. ISBN: 9780309461856.
https://psnet.ahrq.gov/issue/communicating-clearly-about-medicines-proceedings-workshop
Patient h…
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psnet.ahrq.gov/node/72761/psn-pdf
February 17, 2021 - Using ventilator splitters during the COVID-19 pandemic--
letter to health care providers.
February 17, 2021
Silver Spring, MD: Division of Industry and Consumer Education, US Food and Drug Administration;
February 9. 2021.
https://psnet.ahrq.gov/issue/using-ventilator-splitters-during-covid-19-pandemic-letter-hea…
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psnet.ahrq.gov/node/47933/psn-pdf
August 07, 2019 - Just culture: it's more than policy.
August 7, 2019
Paradiso L, Sweeney N. Just culture: It's more than policy. Nurs Manage. 2019;50(6):38-45.
doi:10.1097/01.NUMA.0000558482.07815.ae.
https://psnet.ahrq.gov/issue/just-culture-its-more-policy
This survey study examined the relationship between just culture—a cultur…
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psnet.ahrq.gov/node/47644/psn-pdf
February 13, 2019 - Using computerized virtual cases to explore diagnostic
error in practicing physicians.
February 13, 2019
Trowbridge RL, Reilly JB, Clauser JC, et al. Using computerized virtual cases to explore diagnostic error in
practicing physicians. Diagnosis (Berl). 2018;5(4):229-233. doi:10.1515/dx-2017-0044.
https://psnet.a…
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psnet.ahrq.gov/node/60851/psn-pdf
August 26, 2020 - Situativity: A Family of Social Cognitive Theories for
Clinical Reasoning and Error.
August 26, 2020
Durning S, Holmboe E, Graber ML, eds. Diagnosis(Berl). 2020;7(3):151-344.
https://psnet.ahrq.gov/issue/situativity-family-social-cognitive-theories-clinical-reasoning-and-error
Challenges to effective clinical reas…
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psnet.ahrq.gov/node/43126/psn-pdf
April 23, 2014 - Safe and appropriate use of insulin and other
antihyperglycemic agents in hospital.
April 23, 2014
Cornish W. Safe and appropriate use of insulin and other antihyperglycemic agents in hospital. Can J
Diabetes. 2014;38(2):94-100. doi:10.1016/j.jcjd.2014.01.002.
https://psnet.ahrq.gov/issue/safe-and-appropriate-use-…
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psnet.ahrq.gov/node/853249/psn-pdf
September 06, 2023 - How does robotic-assisted surgery change OR safety
culture?
September 6, 2023
How does robotic-assisted surgery change OR safety culture? AMA J Ethics. 2023;25(8):E615-E623.
doi:10.1001/amajethics.2023.615.
https://psnet.ahrq.gov/issue/how-does-robotic-assisted-surgery-change-or-safety-culture
The safety culture …
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psnet.ahrq.gov/node/838191/psn-pdf
September 28, 2022 - Improved Diagnostic Accuracy Through Probability-
Based Diagnosis.
September 28, 2022
Rockville, MD: Agency for Healthcare Research and Quality; September 2022. AHRQ Publication No. 22-
0026-3-EF.
https://psnet.ahrq.gov/issue/improved-diagnostic-accuracy-through-probability-based-diagnosis
Correct consideration o…
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psnet.ahrq.gov/node/46143/psn-pdf
June 14, 2017 - Report of the Announced Inspection of Medication Safety
at the Midland Regional Hospital Tullamore, County
Offaly.
June 14, 2017
Dublin, Ireland: Health Information and Quality Authority; May 2017.
https://psnet.ahrq.gov/issue/report-announced-inspection-medication-safety-midland-regional-hospital-
tullamore-coun…
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psnet.ahrq.gov/node/45749/psn-pdf
January 11, 2017 - Instrument count sheets and set reviews as patient safety
tools.
January 11, 2017
Spear J. Instrument Count Sheets and Set Reviews as Patient Safety Tools. AORN J. 2016;104(6):588-
592. doi:10.1016/j.aorn.2016.10.007.
https://psnet.ahrq.gov/issue/instrument-count-sheets-and-set-reviews-patient-safety-tools
Inaccu…
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psnet.ahrq.gov/node/43672/psn-pdf
November 12, 2014 - Is a tired doctor a safe doctor?
November 12, 2014
Goldman B. "White Coat, Black Art." CBC Radio. October 31, 2014.
https://psnet.ahrq.gov/issue/tired-doctor-safe-doctor
This radio segment explores whether sleep deprivation affects the safety of care delivery. Panelists discuss
sleep deprivation in health care, th…
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psnet.ahrq.gov/node/45567/psn-pdf
October 12, 2016 - Insulin Pens Devices.
October 12, 2016
Am J Health Syst Pharm. 2016;73(19 suppl 5);s1-s47.
https://psnet.ahrq.gov/issue/insulin-pens-devices
As a high-alert medication, insulin has the potential to result in serious patient harm if administered
incorrectly. Articles in this special issue discuss recommendations de…
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psnet.ahrq.gov/node/46714/psn-pdf
January 10, 2018 - A system-based approach to managing patient safety in
ambulatory care (and beyond).
January 10, 2018
Burger C, Eaton P, Hess K, et al. Patient Saf Qual Healthc. December 12, 2017.
https://psnet.ahrq.gov/issue/system-based-approach-managing-patient-safety-ambulatory-care-and-beyond
Systems-based improvements are ke…
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psnet.ahrq.gov/node/43406/psn-pdf
August 06, 2014 - A comparison of the effects of different typographical
methods on the recognizability of printed drug names.
August 6, 2014
Or CKL, Wang H. A comparison of the effects of different typographical methods on the recognizability of
printed drug names. Drug Saf. 2014;37(5):351-9. doi:10.1007/s40264-014-0156-9.
https:/…
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psnet.ahrq.gov/node/39903/psn-pdf
January 19, 2011 - Assessing teamwork attitudes in healthcare: development
of the TeamSTEPPS teamwork attitudes questionnaire.
January 19, 2011
Baker DP, Amodeo AM, Krokos KJ, et al. Assessing teamwork attitudes in healthcare: development of the
TeamSTEPPS teamwork attitudes questionnaire. Qual Saf Health Care. 2010;19(6):e49.
doi:1…
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psnet.ahrq.gov/node/42911/psn-pdf
February 12, 2014 - Computerized physician order entry: promise, perils, and
experience.
February 12, 2014
Khanna R, Yen T. Computerized physician order entry: promise, perils, and experience. Neurohospitalist.
2014;4(1):26-33. doi:10.1177/1941874413495701.
https://psnet.ahrq.gov/issue/computerized-physician-order-entry-promise-peril…
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psnet.ahrq.gov/node/40758/psn-pdf
September 07, 2011 - A review of educational strategies to improve nurses'
roles in recognizing and responding to deteriorating
patients.
September 7, 2011
Liaw SY, Scherpbier A, Klainin-Yobas P, et al. A review of educational strategies to improve nurses' roles
in recognizing and responding to deteriorating patients. Int Nurs Rev. 20…
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psnet.ahrq.gov/node/43321/psn-pdf
August 02, 2015 - Costs associated with surgical site infections in Veterans
Affairs hospitals.
August 2, 2015
Schweizer ML, Cullen JJ, Perencevich E, et al. Costs Associated With Surgical Site Infections in Veterans
Affairs Hospitals. JAMA Surg. 2014;149(6):575-81. doi:10.1001/jamasurg.2013.4663.
https://psnet.ahrq.gov/issue/costs…
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psnet.ahrq.gov/node/43249/psn-pdf
June 18, 2014 - Automated and electronically assisted hand hygiene
monitoring systems: a systematic review.
June 18, 2014
Ward MA, Schweizer ML, Polgreen PM, et al. Automated and electronically assisted hand hygiene
monitoring systems: a systematic review. Am J Infect Control. 2014;42(5):472-8.
doi:10.1016/j.ajic.2014.01.002.
ht…
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psnet.ahrq.gov/node/864864/psn-pdf
March 20, 2024 - Systemic failures in health care oversight.
March 20, 2024
Campbell JL. Ga L Rev. 2024;58(2):737-802.
https://psnet.ahrq.gov/issue/systemic-failures-health-care-oversight
Questions exist as to why practitioners with known performance issues continue to practice and affect
patient safety. This article suggests a sh…