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psnet.ahrq.gov/node/41458/psn-pdf
June 19, 2012 - What stops hospital clinical staff from following
protocols? An analysis of the incidence and factors
behind the failure of bedside clinical staff to activate the
rapid response system in a multi-campus Australian
metropolitan healthcare service.
June 19, 2012
Shearer B, Marshall S, Buist MD, et al. What stops ho…
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psnet.ahrq.gov/node/39463/psn-pdf
February 10, 2015 - Mixed results in the safety performance of computerized
physician order entry.
February 10, 2015
Metzger J, Welebob E, Bates DW, et al. Mixed results in the safety performance of computerized physician
order entry. Health Aff (Millwood). 2010;29(4):655-663. doi:10.1377/hlthaff.2010.0160.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/47307/psn-pdf
December 12, 2018 - Are teaching hospitals treated fairly in the Hospital-
Acquired Condition Reduction Program?
December 12, 2018
Mohajer MA, Joiner KA, Nix DE. Are Teaching Hospitals Treated Fairly in the Hospital-Acquired Condition
Reduction Program? Acad Med. 2018;93(12):1827-1832. doi:10.1097/ACM.0000000000002399.
https://psnet.…
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psnet.ahrq.gov/node/46704/psn-pdf
December 04, 2018 - Surveying care teams after in-hospital deaths to identify
preventable harm and opportunities to improve advance
care planning.
December 4, 2018
Lucier D, Folcarelli P, Totte C, et al. Surveying Care Teams after in-Hospital Deaths to Identify Preventable
Harm and Opportunities to Improve Advance Care Planning. Jt C…
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psnet.ahrq.gov/node/44976/psn-pdf
February 14, 2017 - Do patients' disruptive behaviours influence the accuracy
of a doctor's diagnosis? A randomised experiment.
February 14, 2017
Schmidt HG, Van Gog T, Schuit SC, et al. Do patients' disruptive behaviours influence the accuracy of a
doctor's diagnosis? A randomised experiment. BMJ Qual Saf. 2017;26(1):19-23. doi:10.11…
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psnet.ahrq.gov/node/44643/psn-pdf
July 21, 2016 - Differing perceptions of safety culture across job roles in
the ambulatory setting: analysis of the AHRQ Medical
Office Survey on Patient Safety Culture.
July 21, 2016
Hickner J, Smith SA, Yount N, et al. Differing perceptions of safety culture across job roles in the
ambulatory setting: analysis of the AHRQ Medic…
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psnet.ahrq.gov/node/39604/psn-pdf
November 23, 2016 - Improving the patient, family, and clinician experience
after harmful events: the "When Things Go Wrong"
curriculum.
November 23, 2016
Bell SK, Moorman D, Delbanco T. Improving the patient, family, and clinician experience after harmful
events: the "when things go wrong" curriculum. Acad Med. 2010;85(6):1010-1017.…
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psnet.ahrq.gov/node/37167/psn-pdf
February 03, 2011 - Mortality among patients in VA hospitals in the first 2
years following ACGME resident duty hour reform.
February 3, 2011
Volpp KG, Rosen AK, Rosenbaum PR, et al. Mortality among patients in VA hospitals in the first 2 years
following ACGME resident duty hour reform. JAMA. 2007;298(9):984-92.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/44721/psn-pdf
August 20, 2016 - Tall Man lettering and potential prescription errors: a time
series analysis of 42 children's hospitals in the USA over
9 years.
August 20, 2016
Zhong W, Feinstein JA, Patel NS, et al. Tall Man lettering and potential prescription errors: a time series
analysis of 42 children's hospitals in the USA over 9 years. B…
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psnet.ahrq.gov/issue/lessons-event-reports
January 16, 2025 - Multi-use Website
Lessons from Event Reports.
Citation Text:
Lessons from Event Reports. Patient Safety Authority.
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psnet.ahrq.gov/node/45220/psn-pdf
June 08, 2016 - Medical Office Survey on Patient Safety Culture: 2016
User Comparative Database Report.
June 8, 2016
Famolaro T, Yount ND, Hare R, Thornton S, Sorra J. Rockville, MD: Agency for Healthcare Research and
Quality; May 2016. AHRQ Publication No. 16-0028-EF.
https://psnet.ahrq.gov/issue/medical-office-survey-patient-sa…
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psnet.ahrq.gov/node/43865/psn-pdf
May 01, 2015 - Computerised physician order entry-related medication
errors: analysis of reported errors and vulnerability
testing of current systems.
May 1, 2015
Schiff GD, Amato MG, Eguale T, et al. Computerised physician order entry-related medication errors:
analysis of reported errors and vulnerability testing of current sy…
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psnet.ahrq.gov/node/42510/psn-pdf
August 21, 2013 - Root cause analysis reports help identify common factors
in delayed diagnosis and treatment of outpatients.
August 21, 2013
Giardina TD, King BJ, Ignaczak AP, et al. Root cause analysis reports help identify common factors in
delayed diagnosis and treatment of outpatients. Health Aff (Millwood). 2013;32(8):1368-75.…
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psnet.ahrq.gov/primer/rapid-response-systems
July 18, 2024 - Rapid Response Systems
Citation Text:
Rapid Response Systems. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/33569/psn-pdf
June 15, 2024 - Readmissions and Adverse Events After Discharge
June 15, 2024
Readmissions and Adverse Events After Discharge. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
t…
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psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy
March 10, 2021
Also Read the Essay
Citation Text:
In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021.In Conversation With... Libby Hoy and Stephen Hoy. PSNet [internet]. Rockville (MD): Agenc…
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psnet.ahrq.gov/node/39116/psn-pdf
April 30, 2014 - Diagnostic error in medicine: analysis of 583 physician-
reported errors.
April 30, 2014
Schiff G, Hasan O, Kim S, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors.
Arch Intern Med. 2009;169(20):1881-1887. doi:10.1001/archinternmed.2009.333.
https://psnet.ahrq.gov/issue/diagnostic-err…
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psnet.ahrq.gov/issue/spread-remains-challenge-patient-safety-improvement
January 23, 2019 - Newspaper/Magazine Article
'Spread' remains challenge in patient safety improvement.
Citation Text:
'Spread' remains challenge in patient safety improvement. Healthcare benchmarks and quality improvement. 2011;18(5):49-52.
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psnet.ahrq.gov/node/840172/psn-pdf
November 16, 2022 - The Stoplight Mobility Alert System for safety and
prevention of falls in children with physical and cognitive
impairments.
November 16, 2022
Mullen JB, Wirt SZ, Moser A, et al. J Patient Saf. 2022;18(6):e947-e952
https://psnet.ahrq.gov/innovation/stoplight-mobility-alert-system-safety-and-prevention-fal…
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psnet.ahrq.gov/issue/why-physicians-err-diagnosis
March 27, 2024 - Commentary
Why physicians err in diagnosis.
Citation Text:
Why physicians err in diagnosis. JAMA. 2015;313(12):1273. doi:10.1001/jama.2014.11660.
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