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psnet.ahrq.gov/node/47629/psn-pdf
July 11, 2019 - How not to waste a crisis: a qualitative study of problem
definition and its consequences in three hospitals.
July 11, 2019
Martin G, Ozieranski P, Leslie M, et al. How not to waste a crisis: a qualitative study of problem definition
and its consequences in three hospitals. J Health Serv Res Policy. 2019;24(3):145-…
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psnet.ahrq.gov/node/845297/psn-pdf
January 01, 2024 - An analysis of prehospital pediatric medication dosing
errors after implementation of a state-wide EMS pediatric
drug dosing reference.
March 1, 2023
Kazi R, Hoyle JD, Huffman C, et al. An analysis of prehospital pediatric medication dosing errors after
implementation of a state-wide EMS pediatric drug dosing refe…
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psnet.ahrq.gov/node/60033/psn-pdf
March 11, 2020 - Interventions to reduce adverse drug event-related
outcomes in older adults: a systematic review and meta-
analysis.
March 11, 2020
Tecklenborg S, Byrne C, Cahir C, et al. Interventions to Reduce Adverse Drug Event-Related Outcomes in
Older Adults: A Systematic Review and Meta-analysis. Drugs Aging. 2020;37(2):91-…
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psnet.ahrq.gov/node/74692/psn-pdf
January 26, 2022 - Changes made to orders placed by overnight admitting
residents on teaching rounds the next day.
January 26, 2022
Chiel L, Freiman E, Yarahuan J, et al. Changes made to orders placed by overnight admitting residents on
teaching rounds the next day. Hosp Pediatr. 2021;12(1):e35-e38. doi:10.1542/hpeds.2021-005823.
ht…
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psnet.ahrq.gov/node/41570/psn-pdf
August 27, 2012 - Exploring relationships between patient safety culture
and patients' assessments of hospital care.
August 27, 2012
Sorra J, Khanna K, Dyer N, et al. Exploring relationships between patient safety culture and patients'
assessments of hospital care. J Patient Saf. 2012;8(3):131-9. doi:10.1097/PTS.0b013e318258ca46.
h…
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psnet.ahrq.gov/node/46871/psn-pdf
July 14, 2018 - Understanding diagnostic safety in emergency medicine:
a case?by?case review of closed ED malpractice claims.
July 14, 2018
Lemoine N, Dajer A, Konwinski J, et al. Understanding diagnostic safety in emergency medicine: A case-
by-case review of closed ED malpractice claims. J Healthc Risk Manag. 2018;38(1):48-53.
…
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psnet.ahrq.gov/node/843415/psn-pdf
February 01, 2023 - Explaining the negative effects of patient participation in
patient safety: an exploratory qualitative study in an
academic tertiary healthcare centre in the Netherlands.
February 1, 2023
Van der Voorden M, Ahaus K, Franx A. Explaining the negative effects of patient participation in patient
safety: an exploratory…
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psnet.ahrq.gov/node/36605/psn-pdf
January 14, 2011 - Drug-related hospitalizations in a tertiary care internal
medicine service of a Canadian hospital: a prospective
study.
January 14, 2011
Samoy LJ, Zed PJ, Wilbur K, et al. Drug-related hospitalizations in a tertiary care internal medicine service
of a Canadian hospital: a prospective study. Pharmacotherapy. 2006;2…
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psnet.ahrq.gov/node/836756/psn-pdf
March 16, 2022 - Quality and safety outcomes of a hospital merger
following a full integration at a safety net hospital.
March 16, 2022
Wang E, Arnold S, Jones S, et al. Quality and safety outcomes of a hospital merger following a full
integration at a safety net hospital. JAMA Netw Open. 2022;5(1):e2142382.
doi:10.1001/jamanetwor…
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psnet.ahrq.gov/node/866745/psn-pdf
September 18, 2024 - State of the Science and Future Directions to Improve
Diagnostic Safety in Older Adults.
September 18, 2024
Tran AK, Syed Q, Bierman AS, et al. State Of The Science And Future Directions To Improve Diagnostic
Safety In Older Adults. Rockville, MD: Agency for Healthcare Research and Quality; September 2024.
AHRQ Pu…
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psnet.ahrq.gov/node/46194/psn-pdf
September 22, 2017 - Mobilising or standing still? A narrative review of Surgical
Safety Checklist knowledge as developed in 25 highly
cited papers from 2009 to 2016.
September 22, 2017
Mitchell B, Cristancho S, Nyhof BB, et al. Mobilising or standing still?A narrative review of Surgical Safety
Checklist knowledge as developed in 25 h…
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psnet.ahrq.gov/node/36902/psn-pdf
June 09, 2010 - Patient handover from surgery to intensive care: using
Formula 1 pit-stop and aviation models to improve safety
and quality.
June 9, 2010
Catchpole K, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using
Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr …
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psnet.ahrq.gov/node/36962/psn-pdf
June 15, 2011 - Rates and types of events reported to established
incident reporting systems in two US hospitals.
June 15, 2011
Nuckols TK, Bell D, Liu H, et al. Rates and types of events reported to established incident reporting
systems in two US hospitals. Qual Saf Health Care. 2007;16(3):164-8.
https://psnet.ahrq.gov/issue/ra…
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psnet.ahrq.gov/node/865662/psn-pdf
April 24, 2024 - Oncologist perceptions of racial disparity, racial anxiety,
and unconscious bias in clinical interactions, treatment,
and outcomes.
April 24, 2024
Balanean A, Bland E, Gajra A, et al. Oncologist perceptions of racial disparity, racial anxiety, and
unconscious bias in clinical interactions, treatment, and outcomes.…
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psnet.ahrq.gov/node/47291/psn-pdf
October 31, 2018 - Incidence and method of suicide in hospitals in the United
States.
October 31, 2018
Williams SC, Schmaltz SP, Castro GM, et al. Incidence and Method of Suicide in Hospitals in the United
States. Jt Comm J Qual Patient Saf. 2018;44(11):643-650. doi:10.1016/j.jcjq.2018.08.002.
https://psnet.ahrq.gov/issue/incidence-…
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psnet.ahrq.gov/node/47283/psn-pdf
January 27, 2019 - Association of the use of a mandatory prescription drug
monitoring program with prescribing practices for
patients undergoing elective surgery.
January 27, 2019
Stucke RS, Kelly JL, Mathis KA, et al. Association of the Use of a Mandatory Prescription Drug Monitoring
Program With Prescribing Practices for Patients …
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psnet.ahrq.gov/node/38176/psn-pdf
October 29, 2008 - Human error, not communication and systems, underlies
surgical complications.
October 29, 2008
Fabri PJ, Zayas-Castro JL. Human error, not communication and systems, underlies surgical
complications. Surgery. 2008;144(4):557-63; discussion 563-5. doi:10.1016/j.surg.2008.06.011.
https://psnet.ahrq.gov/issue/human-e…
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psnet.ahrq.gov/node/849340/psn-pdf
May 24, 2023 - Death Inside Lemuel Shattuck Hospital: A Case Study on
Medical Treatment for Persons with Mental Health
Disabilities.
May 24, 2023
Massachusetts Protection and Advocacy. Boston, MA: Disability Law Center; May 8, 2023.
https://psnet.ahrq.gov/issue/death-inside-lemuel-shattuck-hospital-case-study-medical-treat…
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psnet.ahrq.gov/node/844758/psn-pdf
September 18, 2019 - The fifth vital sign? Nurse worry predicts inpatient
deterioration within 24 hours.
September 18, 2019
Romero-Brufau S, Gaines K, Nicolas CT, et al. JAMIA Open. 2019;2(4):465-470.
https://psnet.ahrq.gov/issue/fifth-vital-sign-nurse-worry-predicts-inpatient-deterioration-within-24-hours
Early recognition of clinica…
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psnet.ahrq.gov/node/45428/psn-pdf
January 25, 2017 - Too many, too few, or too unsafe? Impact of inappropriate
prescribing on mortality, and hospitalization in a cohort of
community-dwelling oldest old.
January 25, 2017
Wauters M, Elseviers M, Vaes B, et al. Too many, too few, or too unsafe? Impact of inappropriate
prescribing on mortality, and hospitalization in a …