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psnet.ahrq.gov/node/48102/psn-pdf
August 07, 2019 - The unmeasured quality metric: burn out and the second
victim syndrome in healthcare.
August 7, 2019
Heiss K, Clifton M. The unmeasured quality metric: Burn out and the second victim syndrome in healthcare.
Semin Pediatr Surg. 2019;28(3):189-194. doi:10.1053/j.sempedsurg.2019.04.011.
https://psnet.ahrq.gov/issue/u…
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psnet.ahrq.gov/node/47064/psn-pdf
August 22, 2018 - Lax oversight leaves surgery center regulators and
patients in the dark.
August 22, 2018
Jewett C, Alesia M. Kaiser Health News. August 9, 2018.
https://psnet.ahrq.gov/issue/lax-oversight-leaves-surgery-center-regulators-and-patients-dark
High-profile failures during office-based procedures have raised awareness o…
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psnet.ahrq.gov/node/45716/psn-pdf
September 29, 2017 - Microanalysis of video from the operating room: an
underused approach to patient safety research.
September 29, 2017
Bezemer J, Cope A, Korkiakangas T, et al. Microanalysis of video from the operating room: an underused
approach to patient safety research. BMJ Qual Saf. 2017;26(7):583-587. doi:10.1136/bmjqs-2016-00…
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psnet.ahrq.gov/node/46786/psn-pdf
May 30, 2018 - Improving patient safety for older people in acute
admissions: implementation of the Frailsafe checklist in
12 hospitals across the UK.
May 30, 2018
Papoutsi C, Poots A, Clements J, et al. Improving patient safety for older people in acute admissions:
implementation of the Frailsafe checklist in 12 hospitals acros…
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psnet.ahrq.gov/node/44080/psn-pdf
September 27, 2017 - A descriptive study of nurse-reported missed care in
neonatal intensive care units.
September 27, 2017
Tubbs-Cooley HL, Pickler RH, Younger JB, et al. A descriptive study of nurse-reported missed care in
neonatal intensive care units. J Adv Nurs. 2015;71(4):813-24. doi:10.1111/jan.12578.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/44735/psn-pdf
January 06, 2016 - Quality and patient safety teams in the perioperative
setting.
January 6, 2016
Serino MF. Quality and Patient Safety Teams in the Perioperative Setting. AORN J. 2015;102(6):617-28.
doi:10.1016/j.aorn.2015.10.006.
https://psnet.ahrq.gov/issue/quality-and-patient-safety-teams-perioperative-setting
Team effectivenes…
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psnet.ahrq.gov/node/45271/psn-pdf
August 10, 2016 - Patient identification and tube labelling—a call for
harmonisation.
August 10, 2016
van Dongen-Lases EC, Cornes MP, Grankvist K, et al. Patient identification and tube labelling – a call for
harmonisation. Clinical Chemistry and Laboratory Medicine (CCLM). 2016;54(7). doi:10.1515/cclm-2015-
1089.
https://psnet.ah…
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psnet.ahrq.gov/node/44439/psn-pdf
September 16, 2015 - Color-coded prefilled medication syringes decrease time
to delivery and dosing errors in simulated prehospital
pediatric resuscitations: a randomized crossover trial.
September 16, 2015
Stevens AD, Hernandez C, Jones S, et al. Color-coded prefilled medication syringes decrease time to
delivery and dosing errors in…
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psnet.ahrq.gov/node/44348/psn-pdf
September 04, 2016 - Examining the attitudes of hospital pharmacists to
reporting medication safety incidents using the theory of
planned behaviour.
September 4, 2016
Williams SD, Phipps D, Ashcroft DM. Examining the attitudes of hospital pharmacists to reporting
medication safety incidents using the theory of planned behaviour. Int J…
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psnet.ahrq.gov/node/73170/psn-pdf
April 21, 2021 - Sentinel Event Alert 63: optimizing smart infusion pump
safety with DERS.
April 21, 2021
Sentinel Event Alert 63: Optimizing Smart Infusion Pump Safety with DERS. Jt Comm J Qual Patient Saf.
2021;47(6):394-397. doi:10.1016/j.jcjq.2021.03.013.
https://psnet.ahrq.gov/issue/sentinel-event-alert-63-optimizing-smart-in…
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psnet.ahrq.gov/node/74721/psn-pdf
February 02, 2022 - Hospital at Home: setting a regulatory course to ensure
safe, high-quality care.
February 2, 2022
DeCherrie LV, Leff B, Levine DM, et al. Hospital at Home: setting a regulatory course to ensure safe, high-
quality care. Jt Comm J Qual Patient Saf. 2022;48(3):180-184. doi:10.1016/j.jcjq.2021.12.003.
https://psnet.a…
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psnet.ahrq.gov/node/44836/psn-pdf
January 27, 2016 - Advancing the next generation of handover research and
practice with cognitive load theory.
January 27, 2016
Young JQ, Wachter R, Cate OT, et al. Advancing the next generation of handover research and practice
with cognitive load theory. BMJ Qual Saf. 2016;25(2):66-70. doi:10.1136/bmjqs-2015-004181.
https://psnet.…
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psnet.ahrq.gov/node/840167/psn-pdf
November 16, 2022 - 'Reading the Signals' : Maternity and Neonatal Services in
East Kent – the Report of the Independent Investigation.
November 16, 2022
Kirkup B. Department of Health and Social Care. London, England: Crown Copyright; 2022. ISBN:
9781528636759.
https://psnet.ahrq.gov/issue/reading-signals-maternity-and-neonata…
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psnet.ahrq.gov/node/44943/psn-pdf
April 15, 2016 - Evaluation of frequency of paediatric oral liquid
medication dosing errors by caregivers: amoxicillin and
josamycin.
April 15, 2016
Berthe-Aucejo A, Girard D, Lorrot M, et al. Evaluation of frequency of paediatric oral liquid medication
dosing errors by caregivers: amoxicillin and josamycin. Arch Dis Child. 2016;1…
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psnet.ahrq.gov/node/47724/psn-pdf
March 20, 2019 - Understanding patient safety and quality outcome data.
March 20, 2019
Easter K, Tamburri LM. Understanding Patient Safety and Quality Outcome Data. Crit Care Nurse.
2018;38(6):58-66. doi:10.4037/ccn2018979.
https://psnet.ahrq.gov/issue/understanding-patient-safety-and-quality-outcome-data
Public reporting of safet…
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psnet.ahrq.gov/node/73575/psn-pdf
August 04, 2021 - Unlocking Solutions in Imaging: Working Together to
Learn from Failings in the NHS.
August 4, 2021
Manchester, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016.
https://psnet.ahrq.gov/issue/unlocking-solutions-imaging-working-together-learn-failings-nhs
Lack of appropriate follow up o…
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psnet.ahrq.gov/node/47205/psn-pdf
July 25, 2018 - Teamwork and Teamwork Training in Healthcare.
July 25, 2018
Teamwork and Teamwork Training in Health care: An Integration and a Path Forward. Buljac-Samardzic M,
Dekker-van Doorn C, Maynard MT, eds. Group Org Manag. 2018;43(3):351-527.
doi:10.1177/1059601118774669.
https://psnet.ahrq.gov/issue/teamwork-and-teamwor…
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psnet.ahrq.gov/node/45073/psn-pdf
May 11, 2016 - Promoting patient safety: results of a TeamSTEPPS
initiative.
May 11, 2016
Gaston T, Short N, Ralyea C, et al. Promoting patient safety: results of a TeamSTEPPS initiative. J Nurs
Adm. 2016;46(4):201-207. doi:10.1097/nna.0000000000000333.
https://psnet.ahrq.gov/issue/promoting-patient-safety-results-teamstepps-ini…
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psnet.ahrq.gov/node/846761/psn-pdf
September 29, 2018 - Using clinical simulation to study how to improve quality
and safety in healthcare.
September 29, 2018
Lamé G, Dixon-Woods M. Using clinical simulation to study how to improve quality and safety in
healthcare. BMJ Simul Technol Enhanc Learn. 2018;6(2):87-94. doi:10.1136/bmjstel-2018-000370.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/46131/psn-pdf
December 19, 2017 - Characteristics associated with requests by pathologists
for second opinions on breast biopsies.
December 19, 2017
Geller BM, Nelson HD, Weaver DL, et al. Characteristics associated with requests by pathologists for
second opinions on breast biopsies. J Clin Pathol. 2017;70(11):947-953. doi:10.1136/jclinpath-2016-
…