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psnet.ahrq.gov/issue/identifying-patient-safety-problems-associated-information-technology-general-practice
December 21, 2017 - Study
Identifying patient safety problems associated with information technology in general practice: an analysis of incident reports.
Citation Text:
Magrabi F, Liaw ST, Arachi D, et al. Identifying patient safety problems associated with information technology in general practice: an an…
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psnet.ahrq.gov/issue/social-cost-adverse-medical-events-and-what-we-can-do-about-it
February 10, 2015 - Commentary
The social cost of adverse medical events, and what we can do about it.
Citation Text:
Goodman JC, Villarreal P, Jones B. The social cost of adverse medical events, and what we can do about it. Health Aff (Millwood). 2011;30(4):590-595. doi:10.1377/hlthaff.2010.1256.
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psnet.ahrq.gov/issue/harnessing-event-report-data-identify-diagnostic-error-during-covid-19-pandemic
October 07, 2020 - Study
Harnessing event report data to identify diagnostic error during the COVID-19 pandemic.
Citation Text:
Shen L, Levie A, Singh H, et al. Harnessing event report data to identify diagnostic error during the COVID-19 pandemic. Jt Comm J Qual Patient Saf. 2022;48(2):71-80. doi:10.1016/…
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psnet.ahrq.gov/issue/why-do-systems-responding-concerns-and-complaints-so-often-fail-patients-families-and
June 16, 2021 - Study
Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff?
Citation Text:
Martin GP, Chew S, Dixon-Woods M. Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? A qualita…
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psnet.ahrq.gov/issue/overdose-risk-young-children-women-prescribed-opioids
September 07, 2016 - Study
Overdose risk in young children of women prescribed opioids.
Citation Text:
Finkelstein Y, Macdonald EM, Gonzalez A, et al. Overdose Risk in Young Children of Women Prescribed Opioids. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-2887.
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psnet.ahrq.gov/issue/suffering-silence-qualitative-study-second-victims-adverse-events
February 03, 2021 - Study
Suffering in silence: a qualitative study of second victims of adverse events.
Citation Text:
Ullström S, Sachs MA, Hansson J, et al. Suffering in silence: a qualitative study of second victims of adverse events. BMJ Qual Saf. 2014;23(4):325-331. doi:10.1136/bmjqs-2013-002035.
Co…
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psnet.ahrq.gov/issue/surgical-checklist-implementation-project-impact-variable-who-checklist-compliance-risk
June 22, 2016 - Study
Surgical checklist implementation project: the impact of variable WHO checklist compliance on risk-adjusted clinical outcomes after national implementation: a longitudinal study.
Citation Text:
Mayer EK, Sevdalis N, Rout S, et al. Surgical Checklist Implementation Project: The Impa…
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psnet.ahrq.gov/issue/patient-voices-hospital-safety-during-covid-19-pandemic
March 17, 2021 - Study
Patient voices in hospital safety during the COVID-19 pandemic.
Citation Text:
Groves PS, Bunch JL, Hanrahan KM, et al. Patient voices in hospital safety during the COVID-19 pandemic. Clin Nurs Res. 2023;32(1):105-114. doi:10.1177/10547738221129711.
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psnet.ahrq.gov/issue/organizational-readiness-change-leverage-point-improving-safety-national-nursing-home-survey
August 26, 2020 - Study
Organizational readiness to change as a leverage point for improving safety: a national nursing home survey.
Citation Text:
Quach ED, Kazis LE, Zhao S, et al. Organizational readiness to change as a leverage point for improving safety: a national nursing home survey. BMC Health Ser…
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psnet.ahrq.gov/issue/getting-whole-story-integrating-patient-complaints-and-staff-reports-unsafe-care
January 12, 2022 - Study
Getting the whole story: integrating patient complaints and staff reports of unsafe care.
Citation Text:
van Dael J, Gillespie A, Reader TW, et al. Getting the whole story: Integrating patient complaints and staff reports of unsafe care. J Health Serv Res Policy. 2022;27(1):41-49. …
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psnet.ahrq.gov/issue/improving-patient-safety-through-involvement-patients-development-and-evaluation-novel
October 12, 2016 - Book/Report
Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm.
Citation Text:
Wright J, Lawton R, O’Hara J, et al. Improving…
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psnet.ahrq.gov/issue/patients-experiences-and-perspectives-patient-reported-outcome-measures-clinical-care
October 27, 2021 - Review
Patients' experiences and perspectives of patient-reported outcome measures in clinical care: a systematic review and qualitative meta-synthesis.
Citation Text:
Carfora L, Foley CM, Hagi-Diakou P, et al. Patients’ experiences and perspectives of patient-reported outcome measures i…
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psnet.ahrq.gov/issue/perceptions-providing-safe-care-frail-older-people-home-qualitative-study-based-focus-group
July 29, 2020 - Study
Perceptions of providing safe care for frail older people at home: a qualitative study based on focus group interviews with home care staff.
Citation Text:
Silverglow A, Johansson L, Lidén E, et al. Perceptions of providing safe care for frail older people at home: a qualitative st…
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psnet.ahrq.gov/issue/patient-safety-culture-care-homes-older-people-scoping-review
January 08, 2020 - Review
Patient safety culture in care homes for older people: a scoping review.
Citation Text:
Gartshore E, Waring J, Timmons S. Patient safety culture in care homes for older people: a scoping review. BMC Health Serv Res. 2017;17(1):752. doi:10.1186/s12913-017-2713-2.
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - Retained Surgical Items: Causation and Prevention
Citation Text:
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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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/33763/psn-pdf
March 01, 2014 - How Does Infection Prevention Fit Into a Safety Program?
March 1, 2014
Huang SS. How Does Infection Prevention Fit Into a Safety Program? PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
Perspective
In 1999, the Institute of Medicine (IOM) released the To …
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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/49808/psn-pdf
October 01, 2017 - High-Risk Medications, High-Risk Transfers
October 1, 2017
Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
The Case
A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …
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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…