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psnet.ahrq.gov/node/47997/psn-pdf
May 08, 2019 - Blind spots in the science of safety.
May 8, 2019
Bosk CL, Pedersen KZ. Blind spots in the science of safety. Lancet. 2019;393(10175):978-979.
doi:10.1016/S0140-6736(19)30441-6.
https://psnet.ahrq.gov/issue/blind-spots-science-safety
Safety sciences offer methods to enhance processes and develop organizational cul…
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psnet.ahrq.gov/node/46458/psn-pdf
May 30, 2018 - Development of the Huddle Observation Tool for
structured case management discussions to improve
situation awareness on inpatient clinical wards.
May 30, 2018
Edbrooke-Childs J, Hayes J, Sharples E, et al. Development of the Huddle Observation Tool for structured
case management discussions to improve situation aw…
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psnet.ahrq.gov/node/43789/psn-pdf
August 05, 2015 - Do cell phones belong in the operating room?
August 5, 2015
Luthra S. Kaiser Health News. July 14, 2015.
https://psnet.ahrq.gov/issue/do-cell-phones-belong-operating-room
Distractions can lead to care and process omissions. Reporting on the prevalence of mobile technology in
the operating room and how it can hinde…
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psnet.ahrq.gov/node/851196/psn-pdf
July 05, 2023 - Patient falls while under supervision: trends from incident
reporting.
July 5, 2023
Roberts M. Patient falls while under supervision: trends from incident reporting. Br J Nurs.
2023;32(11):508-513. doi:10.12968/bjon.2023.32.11.508.
https://psnet.ahrq.gov/issue/patient-falls-while-under-supervision-trends-incident-…
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psnet.ahrq.gov/node/46244/psn-pdf
June 28, 2017 - Changing the narratives for patient safety.
June 28, 2017
Pronovost P, Sutcliffe K, Basu L, et al. Changing the narratives for patient safety. Bull World Health Organ.
2017;95(6):478-480. doi:10.2471/BLT.16.178392.
https://psnet.ahrq.gov/issue/changing-narratives-patient-safety
Mental models represent established …
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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/60604/psn-pdf
June 17, 2020 - The limits of current A.I. in health care: patient safety
policing in hospitals.
June 17, 2020
Furrow BR. NE Univ Law Rev. 2020;12(1):1-55.
https://psnet.ahrq.gov/issue/limits-current-ai-health-care-patient-safety-policing-hospitals
Artificial intelligence (AI) has the potential to improve the use of big data to e…
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psnet.ahrq.gov/node/37259/psn-pdf
March 23, 2011 - Using a survey of incident reporting and learning
practices to improve organisational learning at a cancer
care centre.
March 23, 2011
Cooke DL, Dunscombe PB, Lee R. Using a survey of incident reporting and learning practices to improve
organisational learning at a cancer care centre. Qual Saf Health Care. 2007;16…
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psnet.ahrq.gov/node/44445/psn-pdf
September 16, 2015 - Understanding nurses' and physicians' fear of
repercussions for reporting errors: clinician
characteristics, organization demographics, or leadership
factors?
September 16, 2015
Castel ES, Ginsburg LR, Zaheer S, et al. Understanding nurses' and physicians' fear of repercussions for
reporting errors: clinician cha…
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psnet.ahrq.gov/node/44714/psn-pdf
November 25, 2015 - Continuous Improvement of Patient Safety: The Case for
Change in the NHS.
November 25, 2015
Illingworth J. London, UK: The Health Foundation; 2015. ISBN: 9781906461706.
https://psnet.ahrq.gov/issue/continuous-improvement-patient-safety-case-change-nhs
The Francis inquiry uncovered problems in the National Health S…
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psnet.ahrq.gov/node/47774/psn-pdf
April 08, 2019 - Association of emotional intelligence with malpractice
claims: a review.
April 8, 2019
Shouhed D, Beni C, Manguso N, et al. Association of Emotional Intelligence With Malpractice Claims: A
Review. JAMA Surg. 2019;154(3):250-256. doi:10.1001/jamasurg.2018.5065.
https://psnet.ahrq.gov/issue/association-emotional-int…
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psnet.ahrq.gov/node/47233/psn-pdf
November 02, 2018 - The STEP-up programme: engaging all staff in patient
safety.
November 2, 2018
Hamblin-Brown DJ; Ingram J.
https://psnet.ahrq.gov/issue/step-programme-engaging-all-staff-patient-safety
A transparent and respectful hospital culture is the foundation for improving working conditions to reduce
preventable harm. This …
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psnet.ahrq.gov/node/47540/psn-pdf
April 03, 2019 - Medication handling: towards a practical, human-centred
approach.
April 3, 2019
Marshall SD, Chrimes N. Medication handling: towards a practical, human-centred approach. Anaesthesia.
2019;74(3):280-284. doi:10.1111/anae.14482.
https://psnet.ahrq.gov/issue/medication-handling-towards-practical-human-centred-approac…
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psnet.ahrq.gov/node/846168/psn-pdf
March 15, 2023 - Now is the time to routinely ask patients about safety.
March 15, 2023
Gandhi TK. Now Is the Time to Routinely Ask Patients About Safety. Jt Comm J Qual Patient Saf.
2023;49(4):235-236. doi:10.1016/j.jcjq.2023.01.009.
https://psnet.ahrq.gov/issue/now-time-routinely-ask-patients-about-safety
Safety event reporting …
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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/46787/psn-pdf
October 15, 2018 - Institute for Safe Medication Practices International
Mentorship Program.
October 15, 2018
Institute for Safe Medication Practices.
https://psnet.ahrq.gov/issue/institute-safe-medication-practices-international-mentorship-program
Structured interaction with a wide variety of experts and environments enables medica…
-
psnet.ahrq.gov/node/39197/psn-pdf
January 06, 2010 - root-cause-analysis
https://psnet.ahrq.gov/primer/never-events
https://psnet.ahrq.gov/issue/resident-duty-hours-enhancing-sleep-supervision-and-safety
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psnet.ahrq.gov/node/43027/psn-pdf
July 23, 2014 - improving-team-information-sharing-structured-call-out-anaesthetic-emergencies-randomized
https://psnet.ahrq.gov/issue/enhancing-patient-safety-during-hand-offs-standardized-communication-and-teamwork-using-sbar
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psnet.ahrq.gov/node/44513/psn-pdf
September 23, 2015 - recommendations to improve diagnosis, including promoting teamwork among interdisciplinary health care
teams, enhancing
-
psnet.ahrq.gov/node/47516/psn-pdf
December 19, 2018 - Diverse stakeholders in Australia established an agenda for enhancing test result management,
which