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psnet.ahrq.gov/node/73438/psn-pdf
June 30, 2021 - Implementation of patient safety structures and
processes in the patient-centered medical home.
June 30, 2021
Oberlander T, Scholle SH, Marsteller JA, et al. Implementation of patient safety structures and processes in
the patient-centered medical home. J Healthc Qual. 2021;43(6):324-339.
doi:10.1097/jhq.000000000…
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psnet.ahrq.gov/node/37400/psn-pdf
June 30, 2011 - Errors in cancer diagnosis: current understanding and
future directions.
June 30, 2011
Singh H, Sethi S, Raber M, et al. Errors in cancer diagnosis: current understanding and future directions. J
Clin Oncol. 2007;25(31):5009-18.
https://psnet.ahrq.gov/issue/errors-cancer-diagnosis-current-understanding-and-future-…
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psnet.ahrq.gov/node/60900/psn-pdf
September 09, 2020 - State policies for prescription drug monitoring programs
and adverse opioid-related hospital events.
September 9, 2020
Wen K, Johnson P, Jeng PJ, et al. State policies for prescription drug monitoring programs and adverse
opioid-related hospital events. Med Care. 2020;58(7):610-616.
doi:http://doi.org/10.1097/mlr.…
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psnet.ahrq.gov/node/47284/psn-pdf
December 05, 2018 - Preventable anesthesia-related adverse events at a large
tertiary care center: a nine-year retrospective analysis.
December 5, 2018
Curatolo CJ, McCormick PJ, Hyman JB, et al. Preventable Anesthesia-Related Adverse Events at a Large
Tertiary Care Center: A Nine-Year Retrospective Analysis. Jt Comm J Qual Patient Sa…
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psnet.ahrq.gov/node/867228/psn-pdf
December 04, 2024 - Risk factors for wrong-patient medication orders in the
emergency department.
December 4, 2024
Krummrey G, Sauter TC, Hautz WE, et al. Risk factors for wrong-patient medication orders in the
emergency department. JAMIA Open. 2024;7(4):ooae103. doi:10.1093/jamiaopen/ooae103.
https://psnet.ahrq.gov/issue/risk-factor…
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psnet.ahrq.gov/node/74200/psn-pdf
January 01, 2022 - Association of surgeon-patient sex concordance with
postoperative outcomes.
December 22, 2021
Wallis CJD, Jerath A, Coburn N, et al. Association of surgeon-patient sex concordance with postoperative
outcomes. JAMA Surg. 2022;157(2):146-156. doi:10.1001/jamasurg.2021.6339.
https://psnet.ahrq.gov/issue/association-s…
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psnet.ahrq.gov/node/46653/psn-pdf
July 02, 2019 - Evaluating a mobile application for improving clinical
laboratory test ordering and diagnosis.
July 2, 2019
Meyer AND, Thompson PJ, Khanna A, et al. Evaluating a mobile application for improving clinical
laboratory test ordering and diagnosis. J Am Med Inform Assoc. 2018;25(7):841-847.
doi:10.1093/jamia/ocy026.
h…
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psnet.ahrq.gov/node/47947/psn-pdf
May 29, 2019 - Transcription errors of blood glucose values and insulin
errors in an intensive care unit: secondary data analysis
toward electronic medical record–glucometer
interoperability.
May 29, 2019
Sowan AK, Vera A, Malshe A, et al. Transcription Errors of Blood Glucose Values and Insulin Errors in an
Intensive Care Unit…
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psnet.ahrq.gov/node/48096/psn-pdf
June 19, 2019 - When order sets do not align with clinician workflow:
assessing practice patterns in the electronic health
record.
June 19, 2019
Li RC, Wang JK, Sharp C, et al. When order sets do not align with clinician workflow: assessing practice
patterns in the electronic health record. BMJ Qual Saf. 2019;28(12):987-996. doi:…
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psnet.ahrq.gov/node/73506/psn-pdf
July 21, 2021 - Patient-safety incidents during COVID-19 health crisis in
France: An exploratory sequential multi-method study in
primary care.
July 21, 2021
Fournier JP, Amélineau JB, Hild S, et al. Eur J Gen Pract. 2021;27(1):142-151.
https://psnet.ahrq.gov/issue/patient-safety-incidents-during-covid-19-health-crisis-france-exp…
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psnet.ahrq.gov/node/47195/psn-pdf
September 12, 2018 - Diagnostic discordance, health information exchange,
and inter-hospital transfer outcomes: a population study.
September 12, 2018
Usher M, Sahni N, Herrigel D, et al. Diagnostic discordance, health information exchange, and inter-
hospital transfer outcomes: a population study. J Gen Intern Med. 2018;33(9):1447-145…
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psnet.ahrq.gov/node/849602/psn-pdf
May 31, 2023 - Psychosocial processes in healthcare workers: how
individuals' perceptions of interpersonal communication
is related to patient safety threats and higher-quality care.
May 31, 2023
Dietl JE, Derksen C, Keller FM, et al. Psychosocial processes in healthcare workers: how individuals'
perceptions of interpersonal com…
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psnet.ahrq.gov/node/850159/psn-pdf
June 07, 2023 - Underreporting of quality measures and associated
facility characteristics and racial disparities in US nursing
home ratings.
June 7, 2023
Sanghavi P, Chen Z. Underreporting of quality measures and associated facility characteristics and racial
disparities in US nursing home ratings. JAMA Netw Open. 2023;6(5):e231…
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psnet.ahrq.gov/node/48064/psn-pdf
June 12, 2019 - Lives Lost, Lives Saved: An Updated Comparative
Analysis of Avoidable Deaths at Hospitals Graded by The
Leapfrog Group.
June 12, 2019
Austin M, Derk J. Baltimore, MD: Armstrong Institute for Patient Safety and Quality, and Johns Hopkins
Medicine; May 2019.
https://psnet.ahrq.gov/issue/lives-lost-lives-saved-updat…
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psnet.ahrq.gov/node/47618/psn-pdf
January 30, 2019 - Making care better in the pediatric intensive care unit.
January 30, 2019
Wolfe HA, Mack EH. Making care better in the pediatric intensive care unit. Transl Pediatr. 2018;7(4):267-
274. doi:10.21037/tp.2018.09.10.
https://psnet.ahrq.gov/issue/making-care-better-pediatric-intensive-care-unit
Pediatric critical care…
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psnet.ahrq.gov/node/848812/psn-pdf
May 10, 2023 - Perceived discrimination in the community pharmacy: a
cross-sectional, national survey of adults.
May 10, 2023
Baffoe JO, Moczygemba LR, Brown CM. Perceived discrimination in the community pharmacy: a cross-
sectional, national survey of adults. J Am Pharm Assoc (2003). 2023;63(2):518-528.
doi:10.1016/j.japh.2022.…
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psnet.ahrq.gov/node/44117/psn-pdf
December 04, 2016 - The TRANSFORM patient safety project: a microsystem
approach to improving outcomes on inpatient units.
December 4, 2016
Braddock CH, Szaflarski N, Forsey L, et al. The TRANSFORM Patient Safety Project: a microsystem
approach to improving outcomes on inpatient units. J Gen Intern Med. 2015;30(4):425-33.
doi:10.1007…
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psnet.ahrq.gov/node/44246/psn-pdf
November 15, 2016 - RCA2: Improving Root Cause Analyses and Actions to
Prevent Harm.
November 15, 2016
Boston, MA: National Patient Safety Foundation; 2015.
https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm
The National Patient Safety Foundation issued these guidelines for improving root cause a…
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psnet.ahrq.gov/node/847531/psn-pdf
April 12, 2023 - Strengthening open disclosure after incidents in
maternity care: a realist synthesis of international
research evidence.
April 12, 2023
Adams M, Hartley J, Sanford N, et al. Strengthening open disclosure after incidents in maternity care: a
realist synthesis of international research evidence. BMC Health Serv Res.…
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psnet.ahrq.gov/node/46000/psn-pdf
April 26, 2017 - Diagnostic error in the emergency department: follow up
of patients with minor trauma in the outpatient clinic.
April 26, 2017
Moonen P-J, Mercelina L, Boer W, et al. Diagnostic error in the Emergency Department: follow up of
patients with minor trauma in the outpatient clinic. Scand J Trauma Resusc Emerg Med. 2017…