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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/39819/psn-pdf
April 04, 2011 - Performance characteristics of a methodology to quantify
adverse events over time in hospitalized patients.
April 4, 2011
Sharek PJ, Parry G, Goldmann DA, et al. Performance characteristics of a methodology to quantify
adverse events over time in hospitalized patients. Health Serv Res. 2011;46(2):654-78. doi:10.111…
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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/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/node/72778/psn-pdf
February 24, 2021 - Distractions in the cardiac catheterisation laboratory:
impact for cardiologists and patient safety.
February 24, 2021
Mahadevan K, Cowan E, Kalsi N, et al. Distractions in the cardiac catheterisation laboratory: impact for
cardiologists and patient safety. Open Heart. 2020;7(2). doi:10.1136/openhrt-2020-001260.
h…
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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/46947/psn-pdf
March 21, 2018 - Leaving patients to their own devices? Smart technology,
safety and therapeutic relationships.
March 21, 2018
Ho A, Quick O. Leaving patients to their own devices? Smart technology, safety and therapeutic
relationships. BMC Med Ethics. 2018;19(1):18. doi:10.1186/s12910-018-0255-8.
https://psnet.ahrq.gov/issue/leav…
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psnet.ahrq.gov/node/72470/psn-pdf
January 01, 2021 - Safe use of the EHR by medical scribes: a qualitative
study.
November 18, 2020
Ash JS, Corby S, Mohan V, et al. Safe use of the EHR by medical scribes: a qualitative study. J Amer Med
Inform Assoc. 2021;28(2):294-302. doi:10.1093/jamia/ocaa199.
https://psnet.ahrq.gov/issue/safe-use-ehr-medical-scribes-qualitative-…
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psnet.ahrq.gov/node/843325/psn-pdf
February 01, 2023 - Untenable expectations: nurses' work in the context of
medication administration, error, and the organization.
February 1, 2023
Hawkins SF, Morse JM. Untenable expectations: nurses' work in the context of medication administration,
error, and the organization. Glob Qual Nurs Res. 2022;9:233339362211317.
doi:10.117…
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psnet.ahrq.gov/node/47155/psn-pdf
October 17, 2018 - Medication errors with pediatric liquid acetaminophen
after standardization of concentration and packaging
improvements.
October 17, 2018
Brass EP, Reynolds KM, Burnham RI, et al. Medication Errors With Pediatric Liquid Acetaminophen After
Standardization of Concentration and Packaging Improvements. Acad Pediatr. …
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psnet.ahrq.gov/node/37631/psn-pdf
May 18, 2015 - The science of improvement.
May 18, 2015
Berwick DM. The science of improvement. JAMA. 2008;299(10):1182-4. doi:10.1001/jama.299.10.1182.
https://psnet.ahrq.gov/issue/science-improvement
This commentary by Dr. Donald Berwick, president of the Institute for Healthcare Improvement, addresses
the growing tension betw…
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psnet.ahrq.gov/node/46934/psn-pdf
March 14, 2018 - Engaging the front line: tapping into hospital-wide quality
and safety initiatives.
March 14, 2018
Wolpaw J, Schwengel D, Hensley N, et al. Engaging the Front Line: Tapping into Hospital-Wide Quality
and Safety Initiatives. J Cardiothorac Vasc Anesth. 2018;32(1):522-533. doi:10.1053/j.jvca.2017.05.038.
https://psn…
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psnet.ahrq.gov/node/836758/psn-pdf
March 16, 2022 - Internet of things in healthcare for patient safety: an
empirical study.
March 16, 2022
Yesmin T, Carter MW, Gladman AS. Internet of things in healthcare for patient safety: an empirical study.
BMC Health Serv Res. 2022;22(1):278. doi:10.1186/s12913-022-07620-3.
https://psnet.ahrq.gov/issue/internet-things-healthc…
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psnet.ahrq.gov/node/48035/psn-pdf
May 29, 2019 - Is the future of medical diagnosis in computer
algorithms?
May 29, 2019
Gruber K. Is the future of medical diagnosis in computer algorithms? Lancet Digit Health. 2019;1(1):e15-
e16. doi:10.1016/s2589-7500(19)30011-1.
https://psnet.ahrq.gov/issue/future-medical-diagnosis-computer-algorithms
Artificial intelligence…
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psnet.ahrq.gov/node/42421/psn-pdf
May 19, 2014 - Do drug interaction alerts between a chemotherapy order-
entry system and an electronic medical record affect
clinician behavior?
May 19, 2014
Weingart SN, Zhu J, Young-Hong J, et al. Do drug interaction alerts between a chemotherapy order-entry
system and an electronic medical record affect clinician behavior? J …
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psnet.ahrq.gov/node/42862/psn-pdf
January 15, 2014 - VA Health Care: Improvements Needed in Processes
Used to Address Providers' Actions That Contribute to
Adverse Events.
January 15, 2014
Draper D. Washington, DC: United States Government Accountability Office; December 3, 2013.
Publication GAO-14-55.
https://psnet.ahrq.gov/issue/va-health-care-improvements-needed…
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psnet.ahrq.gov/node/44183/psn-pdf
November 03, 2015 - The absence of a drug–disease interaction alert leads to a
child's death.
November 3, 2015
ISMP Medication Safety Alert! Acute Care Edition. May 21, 2015;20:1-4.
https://psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death
The disabling of alerts due to alarm fatigue can hinder the abilit…
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psnet.ahrq.gov/node/73701/psn-pdf
September 15, 2021 - Simulation-based education enhances patient safety
behaviors during central venous catheter placement.
September 15, 2021
Jagneaux T, Caffery TS, Musso MW, et al. Simulation-based education enhances patient safety behaviors
during central venous catheter placement. J Patient Saf. 2021;17(6):425-429.
doi:10.1097/pt…
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psnet.ahrq.gov/node/73417/psn-pdf
June 23, 2021 - Classification of failures in the perception of
conversational agents (CAs) and their implications on
patient safety.
June 23, 2021
Aftab H, Shah SHH, Habli I. Classification of failures in the perception of conversational agents (CAs) and
their implications on patient safety. Stud Health Technol Inform. 2021;281:…
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psnet.ahrq.gov/node/43932/psn-pdf
March 04, 2015 - Safety considerations to mitigate the risks of
misconnections with small-bore connectors intended for
enteral applications.
March 4, 2015
Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration; February
11, 2015.
https://psnet.ahrq.gov/issue/safety-considerations-mitigate-risks…