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psnet.ahrq.gov/node/40263/psn-pdf
March 02, 2011 - Trauma resuscitation errors and computer-assisted
decision support.
March 2, 2011
FitzGerald M, Cameron P, Mackenzie CF, et al. Trauma resuscitation errors and computer-assisted
decision support. Arch Surg. 2011;146(2):218-25. doi:10.1001/archsurg.2010.333.
https://psnet.ahrq.gov/issue/trauma-resuscitation-errors-…
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psnet.ahrq.gov/node/60704/psn-pdf
July 22, 2020 - Planning for a pandemic: mitigating risk to radiation
therapy service delivery in the COVID-19 era.
July 22, 2020
Anderson N, Thompson K, Andrews J, et al. Planning for a pandemic: mitigating risk to radiation therapy
service delivery in the COVID?19 era. J Med Radiat Sci. 2020;67(3):243-248. doi:10.1002/jmrs.406.
…
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psnet.ahrq.gov/node/866447/psn-pdf
August 07, 2024 - Older adults are often misdiagnosed. Specialized ERs and
trained clinicians can help.
August 7, 2024
Milne-Tyte A. Older adults are often misdiagnosed. Specialized ERs and trained clinicians can help. Health
Shots. National Public Radio. July 30, 2024;
https://psnet.ahrq.gov/issue/older-adults-are-often-misdiagnos…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/poster-4x6-delirium.pdf
June 01, 2021 - Identifying Delirium: ABCs of Identification_4x6
AHRQ Pub. No. 17(21)-0029
June 2021
IDENTIFYING DELIRIUM
ABCs OF IDENTIFICATION
Acute/subacute
• Altered mental status from baseline
Behavioral disturbance
• Restless, agitated, combative
Changes in consciousness
• Jittery, drowsy, difficult to aro…
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psnet.ahrq.gov/node/853073/psn-pdf
August 30, 2023 - Mind the power gap: how hierarchical leadership in
healthcare is a risk to patient safety.
August 30, 2023
Kanaris C. Mind the power gap: how hierarchical leadership in healthcare is a risk to patient safety. J Child
Health Care. 2023;27(3):319-322. doi:10.1177/13674935231196197.
https://psnet.ahrq.gov/issue/mind-…
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psnet.ahrq.gov/node/45563/psn-pdf
October 19, 2016 - Using a change model to reduce the risk of surgical site
infection.
October 19, 2016
Burden M. Using a change model to reduce the risk of surgical site infection. Br J Nurs. 2016;25(17):949-
955.
https://psnet.ahrq.gov/issue/using-change-model-reduce-risk-surgical-site-infection
Surgical site infections can resul…
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psnet.ahrq.gov/node/47982/psn-pdf
July 31, 2019 - Walking the plank: an experimental paradigm to
investigate safety voice.
July 31, 2019
Noort MC, Reader TW, Gillespie A. Walking the Plank: An Experimental Paradigm to Investigate Safety
Voice. Front Psychol. 2019;10:668. doi:10.3389/fpsyg.2019.00668.
https://psnet.ahrq.gov/issue/walking-plank-experimental-paradig…
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psnet.ahrq.gov/node/45617/psn-pdf
November 30, 2016 - Walking a tightrope: balancing the risk of diagnostic error
in inpatient pediatrics.
November 30, 2016
Berkwitt A, Osborn R, Grossman M. Walking a Tightrope: Balancing the Risk of Diagnostic Error in
Inpatient Pediatrics. Hosp Pediatr. 2016;6(9):566-8. doi:10.1542/hpeds.2016-0043.
https://psnet.ahrq.gov/issue/walk…
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psnet.ahrq.gov/node/60955/psn-pdf
September 30, 2020 - The emergency department trigger tool: a novel approach
to screening for quality and safety events.
September 30, 2020
Griffey RT, Schneider RM, Todorov AA. The emergency department trigger tool: a novel approach to
screening for quality and safety events. Ann Emerg Med. 2020;76(2):230-240.
doi:10.1016/j.annemergm…
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psnet.ahrq.gov/node/43926/psn-pdf
April 22, 2015 - The impact of a nurse led rapid response system on
adverse, major adverse events and activation of the
medical emergency team.
April 22, 2015
Massey D, Aitken LM, Chaboyer W. The impact of a nurse led rapid response system on adverse, major
adverse events and activation of the medical emergency team. Intensive Cri…
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psnet.ahrq.gov/node/47693/psn-pdf
January 23, 2019 - Solving alarm fatigue with smartphone technology.
January 23, 2019
Short K, Chung YJ. Solving alarm fatigue with smartphone technology. Nursing (Brux). 2019;49(1):52-57.
doi:10.1097/01.NURSE.0000549728.37810.d9.
https://psnet.ahrq.gov/issue/solving-alarm-fatigue-smartphone-technology
Alarm fatigue contributes to d…
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psnet.ahrq.gov/node/45408/psn-pdf
September 07, 2016 - Effect of warning symbols in combination with education
on the frequency of erroneously crushing medication in
nursing homes: an uncontrolled before and after study.
September 7, 2016
van Welie S, Wijma L, Beerden T, et al. Effect of warning symbols in combination with education on the
frequency of erroneously cru…
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psnet.ahrq.gov/node/837675/psn-pdf
July 13, 2022 - Dashboard design to identify and balance competing risk
of multiple hospital-acquired conditions.
July 13, 2022
Makic MBF, Stevens KR, Gritz RM, et al. Dashboard design to identify and balance competing risk of
multiple hospital-acquired conditions. Appl Clin Inform. 2022;13(3):621-631. doi:10.1055/s-0042-1749598.
…
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psnet.ahrq.gov/node/44730/psn-pdf
December 08, 2015 - Why studying human behavior is a critical component of
patient safety.
December 8, 2015
Su L. Why Studying Human Behavior is a Critical Component of Patient Safety. Curr Probl Pediatr Adolesc
Health Care. 2015;45(12):367-9. doi:10.1016/j.cppeds.2015.10.004.
https://psnet.ahrq.gov/issue/why-studying-human-behavior-…
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psnet.ahrq.gov/node/852283/psn-pdf
January 01, 2024 - Physician engagement in organisational patient safety
through the implementation of a Medical Safety Huddle
initiative: a qualitative study.
August 9, 2023
Rotteau L, Othman D, Dunbar-Yaffe R, et al. Physician engagement in organisational patient safety
through the implementation of a Medical Safety Huddle initiat…
-
psnet.ahrq.gov/node/47224/psn-pdf
June 27, 2018 - Managing Alarms in Acute Care Across the Life Span:
Electrocardiography and Pulse Oximetry.
June 27, 2018
Managing Alarms in Acute Care Across the Life Span: Electrocardiography and Pulse Oximetry. Crit Care
Nurse. 2018;38(2):e16-e20. doi:10.4037/ccn2018468.
https://psnet.ahrq.gov/issue/managing-alarms-acute-care-…
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psnet.ahrq.gov/node/46146/psn-pdf
June 07, 2017 - Increasing patient safety event reporting in an emergency
medicine residency.
June 7, 2017
Steen S, Jaeger C, Price L, et al. Increasing Patient Safety Event Reporting in an Emergency Medicine
Residency. BMJ Qual Improv Rep. 2017;6(1). doi:10.1136/bmjquality.u223876.w5716.
https://psnet.ahrq.gov/issue/increasing-p…
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psnet.ahrq.gov/node/46761/psn-pdf
February 14, 2018 - Development of a theoretical framework of factors
affecting patient safety incident reporting: a theoretical
review of the literature.
February 14, 2018
Archer S, Hull L, Soukup T, et al. Development of a theoretical framework of factors affecting patient safety
incident reporting: a theoretical review of the lite…
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psnet.ahrq.gov/node/46518/psn-pdf
October 29, 2017 - Implementing the Comprehensive Unit-Based Safety
Program (CUSP) to improve patient safety in an academic
primary care practice.
October 29, 2017
Pitts SI, Maruthur NM, Luu N-P, et al. Implementing the Comprehensive Unit-Based Safety Program
(CUSP) to Improve Patient Safety in an Academic Primary Care Practice. Jt …
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psnet.ahrq.gov/node/61077/psn-pdf
October 28, 2020 - Investigation into the Role of Clinical Pharmacy Services
in Helping to Identify and Reduce High-risk Prescribing
Errors in Hospital.
October 28, 2020
Farnborough, UK: Healthcare Safety Investigation Branch; September 24, 2020.
https://psnet.ahrq.gov/issue/investigation-role-clinical-pharmacy-servi…