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psnet.ahrq.gov/node/764403/psn-pdf
March 02, 2022 - Radiologist errors by modality, anatomic region, and
pathology for 1.6 million exams: what we have learned.
March 2, 2022
Lamoureux C, Hanna TN, Sprecher D, et al. Radiologist errors by modality, anatomic region, and pathology
for 1.6 million exams: what we have learned. Emerg Radiol. 2021;28(6):1135-1141. doi:10.1…
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psnet.ahrq.gov/node/866119/psn-pdf
June 12, 2024 - Artificial intelligence in the provision of health care: an
American College of Physicians policy position paper.
June 12, 2024
Daneshvar N, Pandita D, Erickson S, et al. Artificial Intelligence in the Provision of Health Care: An
American College of Physicians Policy Position Paper. Ann Intern Med. 2024;177(7):964…
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psnet.ahrq.gov/node/47725/psn-pdf
March 06, 2019 - Overcoming human barriers to safety event reporting in
radiology.
March 6, 2019
Siewert B, Brook OR, Swedeen S, et al. Overcoming Human Barriers to Safety Event Reporting in
Radiology. Radiographics. 2019;39(1):251-263. doi:10.1148/rg.2019180135.
https://psnet.ahrq.gov/issue/overcoming-human-barriers-safety-event-…
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psnet.ahrq.gov/node/50622/psn-pdf
November 06, 2019 - Starting elective cardiac surgery after 3 pm does not
impact patient morbidity, mortality, or hospital costs.
November 6, 2019
Axtell AL, Moonsamy P, Melnitchouk S, et al. Starting elective cardiac surgery after 3 pm does not impact
patient morbidity, mortality, or hospital costs. J Thorac Cardiovasc Surg. 2019.
d…
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psnet.ahrq.gov/node/43927/psn-pdf
December 04, 2015 - Patient safety, resident well-being and continuity of care
with different resident duty schedules in the intensive
care unit: a randomized trial.
December 4, 2015
Parshuram CS, Amaral ACKB, Ferguson ND, et al. Patient safety, resident well-being and continuity of
care with different resident duty schedules in the …
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psnet.ahrq.gov/node/34085/psn-pdf
February 09, 2011 - Discussion of medical errors in morbidity and mortality
conferences.
February 9, 2011
Pierluissi E, Fischer M, Campbell AR, et al. Discussion of medical errors in morbidity and mortality
conferences. JAMA. 2003;290(21):2838-2842.
https://psnet.ahrq.gov/issue/discussion-medical-errors-morbidity-and-mortality-confer…
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psnet.ahrq.gov/node/60232/psn-pdf
April 15, 2020 - Sustaining innovations in complex health care
environments: a multiple-case study of rapid response
teams.
April 15, 2020
Stolldorf DP, Havens DS, Jones CB. Sustaining innovations in complex health care environments: a
multiple-case study of rapid response teams. J Patient Saf. 2020;16(1).
doi:10.1097/pts.0000000…
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psnet.ahrq.gov/node/866693/psn-pdf
September 11, 2024 - Care home safety incidents and safeguarding reports
relating to hospital to care home transitions: a
retrospective content analysis.
September 11, 2024
Newman C, Mulrine S, Brittain K, et al. Care home safety incidents and safeguarding reports relating to
hospital to care home transitions: a retrospective content …
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psnet.ahrq.gov/node/48080/psn-pdf
June 12, 2019 - Understanding the healthcare workplace learning culture
through safety and dignity narratives: a UK qualitative
study of multiple stakeholders' perspectives.
June 12, 2019
Sholl S, Scheffler G, Monrouxe L, et al. Understanding the healthcare workplace learning culture through
safety and dignity narratives: a UK qu…
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psnet.ahrq.gov/node/861289/psn-pdf
January 01, 2025 - Assessing the impact of an electronic chemotherapy
order verification checklist on pharmacist reported errors
in oncology infusion centers of a health-system.
January 24, 2024
Wat SK (S), Wesolowski B, Cierniak K, et al. Assessing the impact of an electronic chemotherapy order
verification checklist on pharmacist …
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psnet.ahrq.gov/node/72664/psn-pdf
January 20, 2021 - Delayed flow is a risk to patient safety: a mixed method
analysis of emergency department patient flow.
January 20, 2021
Pryce A, Unwin M, Kinsman L, et al. Delayed flow is a risk to patient safety: A mixed method analysis of
emergency department patient flow. Int Emerg Nurs. 2020;54:100956. doi:10.1016/j.ienj.2020…
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psnet.ahrq.gov/node/60203/psn-pdf
April 08, 2020 - Is my patient ready for a safe transfer to a lower-intensity
care setting? Nursing complexity as an independent
predictor of adverse events risk after ICU discharge.
April 8, 2020
Sanson G, Marino C, Valenti A, et al. Is my patient ready for a safe transfer to a lower-intensity care
setting? Nursing complexity as …
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psnet.ahrq.gov/node/73637/psn-pdf
August 25, 2021 - Failures in Care Coordination and Reviewing a Patient's
Death at the VA Salt Lake City Healthcare System in Utah.
August 25, 2021
Washington, DC: Department of Veterans Affairs, Office of Inspector General. July 29, 2021. Report
No. 21-00657-197.
https://psnet.ahrq.gov/issue/failures-care-coordination-and-re…
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psnet.ahrq.gov/node/41359/psn-pdf
November 21, 2016 - The relationship between organizational culture and
family satisfaction in critical care.
November 21, 2016
Dodek P, Wong H, Heyland DK, et al. The relationship between organizational culture and family
satisfaction in critical care. Crit Care Med. 2012;40(5):1506-12. doi:10.1097/CCM.0b013e318241e368.
https://psne…
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psnet.ahrq.gov/node/43054/psn-pdf
June 16, 2014 - We need to talk: an observational study of the impact of
electronic medical record implementation on hospital
communication.
June 16, 2014
Taylor SP, Ledford R, Palmer V, et al. We need to talk: an observational study of the impact of electronic
medical record implementation on hospital communication. BMJ Qual Saf…
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psnet.ahrq.gov/node/44047/psn-pdf
September 09, 2015 - Linking acknowledgement to action: closing the loop on
non-urgent, clinically significant test results in the
electronic health record.
September 9, 2015
Dalal A, Pesterev BM, Eibensteiner K, et al. Linking acknowledgement to action: closing the loop on non-
urgent, clinically significant test results in the elect…
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psnet.ahrq.gov/node/45529/psn-pdf
October 11, 2017 - Increasing compliance with the World Health Organization
surgical safety checklist—a regional health system's
experience.
October 11, 2017
Gitelis ME, Kaczynski A, Shear T, et al. Increasing compliance with the World Health Organization Surgical
Safety Checklist-A regional health system's experience. Am J Surg. 20…
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psnet.ahrq.gov/node/44818/psn-pdf
February 24, 2018 - Economic evaluation of interventions for prevention of
hospital acquired infections: a systematic review.
February 24, 2018
Arefian H, Vogel M, Kwetkat A, et al. Economic Evaluation of Interventions for Prevention of Hospital
Acquired Infections: A Systematic Review. PLoS One. 2016;11(1):e0146381.
doi:10.1371/jour…
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psnet.ahrq.gov/node/47489/psn-pdf
November 21, 2018 - Impact of the Care Quality Commission on Provider
Performance: Room for Improvement?
November 21, 2018
Smithson R, Richardson E, Roberts J, et al. The King's Fund, Alliance Manchester Business School;
September 2018. ISBN: 9781909029880.
https://psnet.ahrq.gov/issue/impact-care-quality-commission-provider-performa…
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psnet.ahrq.gov/node/47251/psn-pdf
July 25, 2018 - Fail-safe patient ID matching remains just out of reach.
July 25, 2018
Arndt RZ. Mod Healthc. July 14, 2018.
https://psnet.ahrq.gov/issue/fail-safe-patient-id-matching-remains-just-out-reach
Similarities in patient names and clinical situations can result in medical errors. Discussing how digital
technologies can …