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psnet.ahrq.gov/node/35253/psn-pdf
April 06, 2011 - Real time patient safety audits: improving safety every
day.
April 6, 2011
Ursprung R. Real time patient safety audits: improving safety every day. Qual Saf Health Care.
2005;14(4):284-289. doi:10.1136/qshc.2004.012542.
https://psnet.ahrq.gov/issue/real-time-patient-safety-audits-improving-safety-every-day
This p…
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psnet.ahrq.gov/node/37667/psn-pdf
April 02, 2008 - Checklists for assessment and certification of clinical
procedural skills omit essential competencies: a
systematic review.
April 2, 2008
McKinley RK, Strand J, Ward L, et al. Checklists for assessment and certification of clinical procedural
skills omit essential competencies: a systematic review. Med Educ. 2008;…
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psnet.ahrq.gov/node/37156/psn-pdf
October 06, 2011 - Preventable harm occurring to critically ill children.
October 6, 2011
Larsen G, Donaldson AE, Parker HB, et al. Preventable harm occurring to critically ill children. Pediatr Crit
Care Med. 2007;8(4):331-336.
https://psnet.ahrq.gov/issue/preventable-harm-occurring-critically-ill-children
This retrospective cohort…
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psnet.ahrq.gov/node/34674/psn-pdf
December 23, 2008 - Incidence and preventability of adverse drug events in
hospitalized patients.
December 23, 2008
Bates DW, Leape L, Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults.
J Gen Intern Med. 1993;8(6):289-294.
https://psnet.ahrq.gov/issue/incidence-and-preventability-adverse-drug-even…
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psnet.ahrq.gov/node/73332/psn-pdf
May 26, 2021 - An evolving hospital quality star rating system from CMS:
aligning the stars.
May 26, 2021
Bilimoria KY, Barnard C. An evolving hospital quality star rating system from CMS: aligning the stars.
JAMA. 2021;325(21):2151-2152. doi:10.1001/jama.2021.6946.
https://psnet.ahrq.gov/issue/evolving-hospital-quality-star-rat…
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psnet.ahrq.gov/node/862153/psn-pdf
February 07, 2024 - Anticipating patient safety events in psychiatric care.
February 7, 2024
Yerstein MC, SUNDARARAJ DEEPIKA, McClean M, et al. Anticipating patient safety events in psychiatric
care. J Psychiatr Pract. 2024;30(1):68-72. doi:10.1097/pra.0000000000000760.
https://psnet.ahrq.gov/issue/anticipating-patient-safety-events-p…
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psnet.ahrq.gov/node/38663/psn-pdf
May 27, 2009 - Prevention of retained surgical sponges: a decision-
analytic model predicting relative cost-effectiveness.
May 27, 2009
Regenbogen SE, Greenberg CC, Resch SC, et al. Prevention of retained surgical sponges: a decision-
analytic model predicting relative cost-effectiveness. Surgery. 2009;145(5):527-35.
doi:10.1016…
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psnet.ahrq.gov/node/38301/psn-pdf
February 15, 2011 - Defining the incidence of cardiorespiratory instability in
patients in step-down units using an electronic integrated
monitoring system.
February 15, 2011
Hravnak M, Edwards L, Clontz A, et al. Defining the incidence of cardiorespiratory instability in patients in
step-down units using an electronic integrated mon…
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psnet.ahrq.gov/node/45094/psn-pdf
May 04, 2016 - Actions Needed to Improve Newly Enrolled Veterans'
Access to Primary Care.
May 4, 2016
Washington, DC: United States Government Accountability Office; March 18, 2016. Publication GAO-16-
328.
https://psnet.ahrq.gov/issue/actions-needed-improve-newly-enrolled-veterans-access-primary-care
This analysis found that s…
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psnet.ahrq.gov/node/44554/psn-pdf
November 20, 2015 - Hospice diagnosis: polypharmacy—a teachable moment.
November 20, 2015
Larson CK, Kao H. Hospice Diagnosis: Polypharmacy: A Teachable Moment. JAMA Intern Med.
2015;175(11):1750-1751. doi:10.1001/jamainternmed.2015.5253.
https://psnet.ahrq.gov/issue/hospice-diagnosis-polypharmacy-teachable-moment
Overprescribing can…
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psnet.ahrq.gov/node/40308/psn-pdf
April 22, 2011 - Improving patient safety: the comparative views of
patient-safety specialists, workforce staff and managers.
April 22, 2011
Braithwaite J, Westbrook MT, Robinson M, et al. Improving patient safety: the comparative views of patient-
safety specialists, workforce staff and managers. BMJ Qual Saf. 2011;20(5):424-31.
…
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psnet.ahrq.gov/node/46501/psn-pdf
March 20, 2018 - Blind obedience and an unnecessary workup for
hypoglycemia: a teachable moment.
March 20, 2018
Wang EY, Patrick L, Connor DM. Blind Obedience and an Unnecessary Workup for Hypoglycemia: A
Teachable Moment. JAMA Intern Med. 2018;178(2):279-280. doi:10.1001/jamainternmed.2017.7104.
https://psnet.ahrq.gov/issue/blind…
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psnet.ahrq.gov/node/47681/psn-pdf
January 30, 2019 - Infection prevention in the operating room anesthesia
work area.
January 30, 2019
Munoz-Price S, Bowdle A, Johnston L, et al. Infection prevention in the operating room anesthesia work
area. Infect Control Hosp Epidemiol. 2018:1-17. doi:10.1017/ice.2018.303.
https://psnet.ahrq.gov/issue/infection-prevention-operat…
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psnet.ahrq.gov/node/862613/psn-pdf
February 14, 2024 - Standardizing medication reconciliation in a pediatric
emergency department.
February 14, 2024
Sheth S, Bialostozky M, Hollenbach K, et al. Standardizing medication reconciliation in a pediatric
emergency department. Pediatrics. 2024;153(2):e2023061964. doi:10.1542/peds.2023-061964.
https://psnet.ahrq.gov/issue/st…
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psnet.ahrq.gov/node/46650/psn-pdf
July 12, 2018 - Towards a more patient-centered approach to medication
safety.
July 12, 2018
Lee JL, Dy SM, Gurses AP, et al. Towards a More Patient-Centered Approach to Medication Safety. J
Patient Exp. 2018;5(2):83-87. doi:10.1177/2374373517727532.
https://psnet.ahrq.gov/issue/towards-more-patient-centered-approach-medication-s…
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psnet.ahrq.gov/node/47662/psn-pdf
February 21, 2024 - Lucian Leape Patient Safety Fellowship Award.
February 21, 2024
International Society for Quality in Health Care
https://psnet.ahrq.gov/issue/lucian-leape-patient-safety-fellowship-award
Inspired by the work and leadership of Dr. Lucian Leape, this award is a mentoring program to develop
physicians and leaders see…
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psnet.ahrq.gov/node/46763/psn-pdf
January 27, 2019 - Human-simulation-based learning to prevent medication
error: a systematic review.
January 27, 2019
Sarfati L, Ranchon F, Vantard N, et al. Human-simulation-based learning to prevent medication error: A
systematic review. J Eval Clin Pract. 2019;25(1):11-20. doi:10.1111/jep.12883.
https://psnet.ahrq.gov/issue/human…
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psnet.ahrq.gov/node/836856/psn-pdf
April 06, 2022 - To what extent are patients involved in researching safety
in acute mental healthcare?
April 6, 2022
Brierley-Jones L, Ramsey L, Canvin K, et al. To what extent are patients involved in researching safety in
acute mental healthcare? Res Involv Engagem. 2022;8(1):8. doi:10.1186/s40900-022-00337-x.
https://psnet.ahr…
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psnet.ahrq.gov/node/45184/psn-pdf
June 01, 2016 - Measuring patient safety in primary care: the
development and validation of the "Patient Reported
Experiences and Outcomes of Safety in Primary Care"
(PREOS-PC).
June 1, 2016
Ricci-Cabello I, Avery A, Reeves D, et al. Measuring Patient Safety in Primary Care: The Development and
Validation of the "Patient Reporte…
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psnet.ahrq.gov/node/50557/psn-pdf
October 16, 2019 - Effect of an Electronic Medication Reconciliation
Intervention on Adverse Drug Events: A Cluster
Randomized Trial
October 16, 2019
Tamblyn R, Abrahamowicz M, Buckeridge DL, et al. Effect of an Electronic Medication Reconciliation
Intervention on Adverse Drug Events: A Cluster Randomized Trial. JAMA Netw Open. 2019…