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psnet.ahrq.gov/node/837041/psn-pdf
May 04, 2022 - APSF endorsed statement on revising recommendations
for patient monitoring during anesthesia.
May 4, 2022
The APSF Committee on Technology. APSF Newsletter. 2022;37(1):7–8.
https://psnet.ahrq.gov/issue/apsf-endorsed-statement-revising-recommendations-patient-monitoring-during-
anesthesia
Variation across sta…
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psnet.ahrq.gov/node/34998/psn-pdf
June 22, 2009 - Cause and effect analysis of closed claims in obstetrics
and gynecology.
June 22, 2009
White AA, Pichert JW, Bledsoe SH, et al. Cause and effect analysis of closed claims in obstetrics and
gynecology. Obstet Gynecol. 2005;105(5 Pt 1):1031-1038.
https://psnet.ahrq.gov/issue/cause-and-effect-analysis-closed-claims-o…
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psnet.ahrq.gov/node/38046/psn-pdf
September 10, 2008 - Clinical and pathological disagreement upon the cause of
death in a teaching hospital: analysis of 100 autopsy
cases in a prospective study.
September 10, 2008
Pinto Carvalho FL, Cordeiro JA, Cury PM. Clinical and pathological disagreement upon the cause of death
in a teaching hospital: Analysis of 100 autopsy cas…
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psnet.ahrq.gov/node/44252/psn-pdf
January 01, 2016 - Associations between safety culture and employee
engagement over time: a retrospective analysis.
December 16, 2015
Biddison ELD, Paine LA, Murakami P, et al. Associations between safety culture and employee
engagement over time: a retrospective analysis. BMJ Qual Saf. 2016;25(1):31-7. doi:10.1136/bmjqs-2014-
00391…
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psnet.ahrq.gov/node/849615/psn-pdf
May 31, 2023 - Clinical Investigation Booking Systems Failures: Written
Communications in Community Languages.
May 31, 2023
Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.
https://psnet.ahrq.gov/issue/clinical-investigation-booking-systems-failures-written-communications-
community-languages
Gaps in patient…
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psnet.ahrq.gov/node/46717/psn-pdf
April 16, 2018 - Reduction in opioid prescribing through evidence-based
prescribing guidelines.
April 16, 2018
Howard R, Waljee JF, Brummett CM, et al. Reduction in Opioid Prescribing Through Evidence-Based
Prescribing Guidelines. JAMA Surg. 2018;153(3):285-287. doi:10.1001/jamasurg.2017.4436.
https://psnet.ahrq.gov/issue/reductio…
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psnet.ahrq.gov/node/867020/psn-pdf
October 23, 2024 - What can we learn from coroners’ reports on preventable
deaths?
October 23, 2024
Jeraj S. What can we learn from coroners’ reports on preventable deaths? BMJ. 2024;386:q1943.
https://psnet.ahrq.gov/issue/what-can-we-learn-coroners-reports-preventable-deaths
Analysis of system failure is only the beginning of the i…
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psnet.ahrq.gov/node/46670/psn-pdf
December 18, 2017 - A narrative review of the safety concerns of deprescribing
in older adults and strategies to mitigate potential harms.
December 18, 2017
Reeve E, Moriarty F, Nahas R, et al. A narrative review of the safety concerns of deprescribing in older
adults and strategies to mitigate potential harms. Expert Opin Drug Saf. 2…
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psnet.ahrq.gov/node/43616/psn-pdf
October 29, 2014 - Preventing Healthcare-Associated Infections: Results and
Lessons Learned from AHRQ's HAI Program.
October 29, 2014
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Infect Control Hosp Epidemiol. 2014;35(suppl 3):S1-
S141.
https://psnet.ahrq.gov/issue/preventing-healthcare-associated-infections-results-and-lesson…
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psnet.ahrq.gov/node/38070/psn-pdf
March 10, 2011 - Can surveillance systems identify and avert adverse drug
events? A prospective evaluation of a commercial
application.
March 10, 2011
Jha AK, Laguette J, Seger AC, et al. Can surveillance systems identify and avert adverse drug events? A
prospective evaluation of a commercial application. J Am Med Inform Assoc. 20…
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psnet.ahrq.gov/node/39922/psn-pdf
October 13, 2010 - What’s past is prologue: organizational learning from a
serious patient injury.
October 13, 2010
Tamuz M, Franchois KE, Thomas EJ. What’s past is prologue: Organizational learning from a serious
patient injury. Saf Sci. 2010;49(1). doi:10.1016/j.ssci.2010.06.005.
https://psnet.ahrq.gov/issue/whats-past-prologue-or…
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psnet.ahrq.gov/node/854259/psn-pdf
January 01, 2024 - The power of written word: reflection reduces errors of
omission.
October 4, 2023
Rao A, Heidemann LA, Hartley S, et al. The power of written word: reflection reduces errors of omission.
Clin Teach. 2024;21(1):e13630. doi:10.1111/tct.13630.
https://psnet.ahrq.gov/issue/power-written-word-reflection-reduces-errors-…
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psnet.ahrq.gov/node/44520/psn-pdf
September 30, 2015 - Patient safety in dermatologic surgery: parts 1 and 2.
September 30, 2015
Lolis M, Dunbar SW, Goldberg DJ, et al. J Am Acad Dermatol. 2015;73(1):1-26.
https://psnet.ahrq.gov/issue/patient-safety-dermatologic-surgery-part-1-patient-safety-procedural-
dermatology-part-2
This two-part review series explores patient s…
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psnet.ahrq.gov/node/36929/psn-pdf
September 09, 2011 - Nurse working conditions and patient safety outcomes.
September 9, 2011
Stone PW, Mooney-Kane C, Larson EL, et al. Nurse Working Conditions and Patient Safety Outcomes.
Med Care. 2007;45(6):571-578. doi:10.1097/mlr.0b013e3180383667.
https://psnet.ahrq.gov/issue/nurse-working-conditions-and-patient-safety-outcomes
…
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psnet.ahrq.gov/node/45886/psn-pdf
July 05, 2017 - Organizational perspectives of nurse executives in 15
hospitals on the impact and effectiveness of rapid
response teams.
July 5, 2017
Smith PL, McSweeney J. Organizational Perspectives of Nurse Executives in 15 Hospitals on the Impact
and Effectiveness of Rapid Response Teams. Jt Comm J Qual Patient Saf. 2017;43(6…
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psnet.ahrq.gov/node/838125/psn-pdf
September 22, 2022 - Frontiers in measuring structural racism and its health
effects.
September 22, 2022
Brown TH, Homan PA. Frontiers in measuring structural racism and its health effects. Health Serv Res.
2022;57(3):443-447. doi:10.1111/1475-6773.13978.
https://psnet.ahrq.gov/issue/frontiers-measuring-structural-racism-and-its-healt…
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psnet.ahrq.gov/node/74065/psn-pdf
November 10, 2021 - AHRQ announces interest in research on digital
healthcare safety.
November 10, 2021
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 28, 2021
Publication No. NOT-HS-22-004.
https://psnet.ahrq.gov/issue/ahrq-announces-interest-research-digital-healthcare-safety
Digital in…
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psnet.ahrq.gov/node/37761/psn-pdf
May 14, 2008 - Student perceptions of medical errors: incorporating an
explicit professionalism curriculum in the third-year
surgery clerkship.
May 14, 2008
Newell P, Harris S, Aufses A, et al. Student perceptions of medical errors: incorporating an explicit
professionalism curriculum in the third-year surgery clerkship. J Surg …
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psnet.ahrq.gov/node/44833/psn-pdf
April 22, 2016 - The contribution of sociotechnical factors to health
information technology–related sentinel events.
April 22, 2016
Castro GM, Buczkowski L, Hafner JM. The Contribution of Sociotechnical Factors to Health Information
Technology-Related Sentinel Events. Jt Comm J Qual Patient Saf. 2016;42(2):70-76.
https://psnet.ah…
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psnet.ahrq.gov/node/45485/psn-pdf
July 01, 2017 - Psychological responses, coping and supporting needs
of healthcare professionals as second victims.
July 1, 2017
Chan ST, Khong PCB, Wang W. Psychological responses, coping and supporting needs of healthcare
professionals as second victims. Intern Nurs Rev. 2017;64(2):242-262. doi:10.1111/inr.12317.
https://psnet.…