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psnet.ahrq.gov/node/47684/psn-pdf
March 20, 2019 - The impact of mobile technology on teamwork and
communication in hospitals: a systematic review.
March 20, 2019
Martin G, Khajuria A, Arora S, et al. The impact of mobile technology on teamwork and communication in
hospitals: a systematic review. J Am Med Inform Assoc. 2019;26(4):339-355. doi:10.1093/jamia/ocy175.
…
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psnet.ahrq.gov/node/853630/psn-pdf
September 20, 2023 - California pharmacies are making millions of mistakes.
They’re fighting to keep that secret.
September 20, 2023
Peterson M. Los Angeles Times. September 5, 2023.
https://psnet.ahrq.gov/issue/california-pharmacies-are-making-millions-mistakes-theyre-fighting-keep-secret
Safe practice in community pharmacy is challe…
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psnet.ahrq.gov/node/848827/psn-pdf
May 10, 2023 - TQIP Mortality Reporting System Case Reports.
May 10, 2023
ACS TQIP Mortality Reporting System Writing Group. J Trauma Acute Care Surg. 2023.
https://psnet.ahrq.gov/issue/tqip-mortality-reporting-system-case-reports
Anonymous case reporting provides opportunities to examine unexpected patient harm instances to
pin…
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psnet.ahrq.gov/node/40545/psn-pdf
June 22, 2011 - Using ORA to explore the relationship of nursing unit
communication to patient safety and quality outcomes.
June 22, 2011
Effken JA, Carley KM, Gephart SM, et al. Using ORA to explore the relationship of nursing unit
communication to patient safety and quality outcomes. Int J Med Inform. 2011;80(7):507-17.
doi:10.…
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psnet.ahrq.gov/node/72687/psn-pdf
January 27, 2021 - Learning from errors with the new COVID-19 vaccines.
January 27, 2021
ISMP Medication Safety Alert! Acute Care Edition. January 14, 2021;26(1);1-5.
https://psnet.ahrq.gov/issue/learning-errors-new-covid-19-vaccines
Learning from error rests on transparency efforts buttressed by frontline reports. This a…
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psnet.ahrq.gov/node/44525/psn-pdf
October 21, 2015 - Wound-care teams for preventing and treating pressure
ulcers.
October 21, 2015
Moore ZEH, Webster J, Samuriwo R. Wound-care teams for preventing and treating pressure ulcers.
Cochrane Database Syst Rev. 2015;9:CD011011. doi:10.1002/14651858.CD011011.pub2.
https://psnet.ahrq.gov/issue/wound-care-teams-preventing-an…
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psnet.ahrq.gov/node/842769/psn-pdf
January 18, 2023 - Production pressure and its relationship to safety: a
systematic review and future directions.
January 18, 2023
Hashemian SM, Triantis K. Production pressure and its relationship to safety: a systematic review and
future directions. Safety Sci. 2023;159:106045. doi:10.1016/j.ssci.2022.106045.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/48043/psn-pdf
October 01, 2023 - Health Services Safety Investigations Body.
October 1, 2023
Lytchett House, 13 Freeland Park, Wareham Road, Poole, Dorset, BH16 6FA.
https://psnet.ahrq.gov/issue/health-services-safety-investigations-body
Independent investigations examine system weaknesses in health care to inform improvement, reduce risk,
and pr…
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psnet.ahrq.gov/node/866823/psn-pdf
September 25, 2024 - Understanding human factors in patient safety when
prescribing.
September 25, 2024
Coon R, Holden K. Understanding human factors in patient safety when prescribing. Pharmaceutical
Journal. September 2024;313(7989).
https://psnet.ahrq.gov/issue/understanding-human-factors-patient-safety-when-prescribing
Prescripti…
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psnet.ahrq.gov/node/47933/psn-pdf
August 07, 2019 - Just culture: it's more than policy.
August 7, 2019
Paradiso L, Sweeney N. Just culture: It's more than policy. Nurs Manage. 2019;50(6):38-45.
doi:10.1097/01.NUMA.0000558482.07815.ae.
https://psnet.ahrq.gov/issue/just-culture-its-more-policy
This survey study examined the relationship between just culture—a cultur…
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psnet.ahrq.gov/node/61003/psn-pdf
October 07, 2020 - Making Complaints Count: Supporting Complaints
Handling in the NHS and UK Government Departments.
October 7, 2020
Manchester, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN
9781528620666.
https://psnet.ahrq.gov/issue/making-complaints-count-supporting-complaints-handling-nhs-and-uk-
gover…
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psnet.ahrq.gov/node/35176/psn-pdf
June 23, 2009 - Mapping changes in surgical mortality over 9 years by
peer review audit.
June 23, 2009
Thompson A, Ashraf Z, Burton H, et al. Mapping changes in surgical mortality over 9 years by peer review
audit. Br J Surg. 2005;92(11):1449-52.
https://psnet.ahrq.gov/issue/mapping-changes-surgical-mortality-over-9-years-peer-re…
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psnet.ahrq.gov/node/74765/psn-pdf
February 09, 2022 - Whose responsibility is it to address bullying in health
care?
February 9, 2022
Whose responsibility is it to address bullying in health care? AMA J Ethics. 2022;23(12):E931-936.
doi:10.1001/amajethics.2021.931.
https://psnet.ahrq.gov/issue/whose-responsibility-it-address-bullying-health-care
Disrespectful behavi…
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psnet.ahrq.gov/node/837038/psn-pdf
May 04, 2022 - Mind the Implementation Gap. The Persistence of
Avoidable Harm in the NHS.
May 4, 2022
London UK: Patient Safety Learning: 2022.
https://psnet.ahrq.gov/issue/mind-implementation-gap-persistence-avoidable-harm-nhs
Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financi…
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psnet.ahrq.gov/node/47855/psn-pdf
June 19, 2019 - Medication Overload: America's Other Drug Problem.
June 19, 2019
Brownlee S; Garber J. Brookline, MA: Lown Institute; 2019.
https://psnet.ahrq.gov/issue/medication-overload-americas-other-drug-problem
Overprescribing is a common problem that contributes to patient harm. This report examines financial,
clinical, an…
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psnet.ahrq.gov/node/60607/psn-pdf
June 17, 2020 - When health care moves online, many patients are left
behind.
June 17, 2020
Renault M. When health care moves online, many patients are left behind. Wired Online. 2020;(June 8,
2020).
https://psnet.ahrq.gov/issue/when-health-care-moves-online-many-patients-are-left-behind
The emergence of telemedicine as a primar…
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psnet.ahrq.gov/node/38783/psn-pdf
September 02, 2009 - Medical negligence in drug associated deaths.
September 2, 2009
Madea B, Musshoff F, Preuss J. Medical negligence in drug associated deaths. Forensic Sci Int.
2009;190(1-3):67-73. doi:10.1016/j.forsciint.2009.05.014.
https://psnet.ahrq.gov/issue/medical-negligence-drug-associated-deaths
This study reports that acc…
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psnet.ahrq.gov/node/43095/psn-pdf
April 09, 2014 - Intravenous chemotherapy preparation errors: patient
safety risks identified in a pan-Canadian exploratory
study.
April 9, 2014
White R, Cassano-Piché A, Fields A, et al. Intravenous chemotherapy preparation errors: patient safety
risks identified in a pan-Canadian exploratory study. J Oncol Pharm Pract. 2014;20(1…
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psnet.ahrq.gov/node/72762/psn-pdf
February 17, 2021 - Optimizing Health IT for Safe Integration of Behavioral
Health and Primary Care.
February 17, 2021
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.
https://psnet.ahrq.gov/issue/optimizing-health-it-safe-integration-behavioral-health-and-primary-care
Effective integration of hea…
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psnet.ahrq.gov/node/44630/psn-pdf
February 15, 2017 - Reduction of incorrect record accessing and charting
patient electronic medical records in the perioperative
environment.
February 15, 2017
Rebello E, Kee S, Kowalski A, et al. Reduction of incorrect record accessing and charting patient electronic
medical records in the perioperative environment. Health Informati…