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psnet.ahrq.gov/node/44352/psn-pdf
August 12, 2015 - Hospital checklists are meant to save lives—so why do
they often fail?
August 12, 2015
Anthes E. Hospital checklists are meant to save lives - so why do they often fail? Nature.
2015;523(7562):516-8. doi:10.1038/523516a.
https://psnet.ahrq.gov/issue/hospital-checklists-are-meant-save-lives-so-why-do-they-often-fai…
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psnet.ahrq.gov/node/46138/psn-pdf
May 31, 2017 - An innovative collaborative model of care for
undiagnosed complex medical conditions.
May 31, 2017
Nageswaran S, Donoghue N, Mitchell A, et al. An Innovative Collaborative Model of Care for Undiagnosed
Complex Medical Conditions. Pediatrics. 2017;139(5):e20163373. doi:10.1542/peds.2016-3373.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/49392/psn-pdf
April 01, 2003 - Since use of restraints is a very emotional issue and would be evaluated in hindsight,
providers may
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psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
June 14, 2023 - during CPR. 6
In 2015, and again in 2019, the International Liaison Committee on Resuscitation (ILCOR) evaluated
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psnet.ahrq.gov/node/851652/psn-pdf
July 26, 2023 - Breast cancer missed at screening; hindsight or
mistakes?
July 26, 2023
Hovda T, Larsen M, Romundstad L, et al. Breast cancer missed at screening; hindsight or mistakes? Eur J
Radiol. 2023;165:110913. doi:10.1016/j.ejrad.2023.110913.
https://psnet.ahrq.gov/issue/breast-cancer-missed-screening-hindsight-or-mistakes…
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psnet.ahrq.gov/node/46952/psn-pdf
January 01, 2019 - Perspectives on patient and family engagement with
reduction in harm: the forgotten voice.
December 21, 2018
Schenk EC, Bryant RA, Van Son CR, et al. Perspectives on Patient and Family Engagement With
Reduction in Harm: The Forgotten Voice. J Nurs Care Qual. 2019;34(1):73-79.
doi:10.1097/NCQ.0000000000000333.
htt…
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psnet.ahrq.gov/node/74704/psn-pdf
January 26, 2022 - Improving self-reported empathy and communication
skills through harm in healthcare response training.
January 26, 2022
Samuels A, Broome ME, McDonald TB, et al. Improving self-reported empathy and communication skills
through harm in healthcare response training. J Patient Saf Risk Manage. 2021;26(6):251-260.
doi…
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psnet.ahrq.gov/node/45246/psn-pdf
August 15, 2016 - Reliability of verbal handoff assessment and handoff
quality before and after implementation of a resident
handoff bundle.
August 15, 2016
Feraco AM, Starmer AJ, Sectish TC, et al. Reliability of Verbal Handoff Assessment and Handoff Quality
Before and After Implementation of a Resident Handoff Bundle. Acad Pediat…
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psnet.ahrq.gov/node/844763/psn-pdf
September 11, 2019 - Associations between national board exam performance
and residency program emphasis on patient safety and
interprofessional teamwork.
September 11, 2019
Loftus TJ, Hall DJ, Malaty JZ, et al. Associations between national board exam performance and residency
program emphasis on patient safety and interprofessional …
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psnet.ahrq.gov/node/46912/psn-pdf
March 28, 2018 - Ignoring the Alarms: How NHS Eating Disorder Services
Are Failing Patients.
March 28, 2018
London, UK: Parliamentary and Health Service Ombudsman; 2017. ISBN: 9781528601344.
https://psnet.ahrq.gov/issue/ignoring-alarms-how-nhs-eating-disorder-services-are-failing-patients
Patients with mental health conditions fac…
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psnet.ahrq.gov/node/43425/psn-pdf
July 03, 2016 - Graduate medical education's new focus on resident
engagement in quality and safety: will it transform the
culture of teaching hospitals?
July 3, 2016
Myers JS, Nash DB. Graduate Medical Education’s New Focus on Resident Engagement in Quality and
Safety. Acad Med. 2014;89(10):1328-1330. doi:10.1097/acm.00000000000…
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psnet.ahrq.gov/node/44796/psn-pdf
October 06, 2016 - The perceptions of nurses towards barriers to the safe
administration of medicines in mental health settings.
October 6, 2016
Hemingway S, McCann T, Baxter H, et al. The perceptions of nurses towards barriers to the safe
administration of medicines in mental health settings. Int J Nurs Pract. 2015;21(6):733-40.
do…
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psnet.ahrq.gov/node/843082/psn-pdf
January 25, 2023 - Determination of unnecessary blood transfusion by
comprehensive 15-hospital record review.
January 25, 2023
Jadwin DF, Fenderson PG, Friedman MT, et al. Determination of unnecessary blood transfusion by
comprehensive 15-hospital record review. Jt Comm J Qual Patient Saf. 2023;49(1):42-52.
doi:10.1016/j.jcjq.2022.1…
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psnet.ahrq.gov/issue/missed-lesions-abdominal-oncologic-ct-lessons-learned-quality-assurance
April 21, 2011 - October 4, 2011
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/evaluation-12-strategies-obtaining-second-opinions-improve-interpretation-breast
November 03, 2015 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/characteristics-and-predictors-missed-opportunities-lung-cancer-diagnosis-electronic-health
January 19, 2012 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/diagnostic-errors-musculoskeletal-oncology-and-possible-mitigation-strategies
May 01, 2013 - December 27, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/big-dog-effect-variability-assessing-causes-error-diagnoses-patients-lung-cancer
March 28, 2012 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/delayed-or-missed-diagnosis-cervical-spine-injuries
May 05, 2010 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/patient-safety-leadership-academy-university-pennsylvania-first-cohorts-learning-experience
October 04, 2011 - June 18, 2013
Why Current Breast Pathology Practices Must Be Evaluated.