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psnet.ahrq.gov/node/73468/psn-pdf
July 07, 2021 - The implementation of communication didactics for
OB/GYN residents on the disclosure of adverse
perioperative events.
July 7, 2021
Chung EH, Truong T, Jooste KR, et al. The implementation of communication didactics for OB/GYN
residents on the disclosure of adverse perioperative events. J Surg Educ. 2021;78(3):942-…
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psnet.ahrq.gov/node/47155/psn-pdf
October 17, 2018 - Medication errors with pediatric liquid acetaminophen
after standardization of concentration and packaging
improvements.
October 17, 2018
Brass EP, Reynolds KM, Burnham RI, et al. Medication Errors With Pediatric Liquid Acetaminophen After
Standardization of Concentration and Packaging Improvements. Acad Pediatr. …
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psnet.ahrq.gov/node/73858/psn-pdf
September 22, 2021 - Coping with errors in the operating room: intraoperative
strategies, postoperative strategies, and sex differences.
September 22, 2021
D'Angelo JD, Lund S, Busch RA, et al. Coping with errors in the operating room: intraoperative strategies,
postoperative strategies, and sex differences. Surgery. 2021;170(2):440-44…
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psnet.ahrq.gov/node/34868/psn-pdf
February 03, 2011 - Role of computerized physician order entry systems in
facilitating medication errors.
February 3, 2011
Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating
medication errors. JAMA. 2005;293(10):1197-203.
https://psnet.ahrq.gov/issue/role-computerized-physician-ord…
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psnet.ahrq.gov/node/45161/psn-pdf
September 19, 2016 - Design of an evidence-based "second victim" curriculum
for nurse anesthetists.
September 19, 2016
Daniels RG, McCorkle R. Design of an Evidence-Based "Second Victim" Curriculum for Nurse Anesthetists.
AANA J. 2016;84(2):107-113.
https://psnet.ahrq.gov/issue/design-evidence-based-second-victim-curriculum-nurse-anes…
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psnet.ahrq.gov/node/42934/psn-pdf
February 21, 2015 - Outcome of adverse events and medical errors in the
intensive care unit: a systematic review and meta-
analysis.
February 21, 2015
Ahmed AH, Giri J, Kashyap R, et al. Outcome of adverse events and medical errors in the intensive care
unit: a systematic review and meta-analysis. Am J Med Qual. 2015;30(1):23-30.
do…
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psnet.ahrq.gov/node/862993/psn-pdf
February 21, 2024 - Disparities in diagnostic timeliness and outcomes of
pediatric appendicitis.
February 21, 2024
Michelson KA, Bachur RG, Rangel SJ, et al. Disparities in diagnostic timeliness and outcomes of pediatric
appendicitis. JAMA Netw Open. 2024;7(1):e2353667. doi:10.1001/jamanetworkopen.2023.53667.
https://psnet.ahrq.gov/i…
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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/43187/psn-pdf
May 28, 2014 - Governance of quality of care: a qualitative study of
health service boards in Victoria, Australia.
May 28, 2014
Bismark M, Studdert DM. Governance of quality of care: a qualitative study of health service boards in
Victoria, Australia. BMJ Qual Saf. 2014;23(6):474-82. doi:10.1136/bmjqs-2013-002193.
https://psnet.…
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psnet.ahrq.gov/node/863754/psn-pdf
March 06, 2024 - The effect of visitation restrictions on ED error.
March 6, 2024
Marks CM, Wolfe RE, Grossman SA. The effect of visitation restrictions on ED error. Intern Emerg Med.
2024;19(5):1425-1430. doi:10.1007/s11739-024-03537-3.
https://psnet.ahrq.gov/issue/effect-visitation-restrictions-ed-error
At the beginning of the C…
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psnet.ahrq.gov/node/838016/psn-pdf
January 02, 2021 - Racism as a Root Cause approach: a new framework.
January 2, 2021
Malawa Z, Gaarde J, Spellen S. Racism as a Root Cause approach: a new framework. Pediatrics.
2021;147(1):e2020015602. doi:10.1542/peds.2020-015602.
https://psnet.ahrq.gov/issue/racism-root-cause-approach-new-framework
Structural racism, which manife…
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psnet.ahrq.gov/node/41466/psn-pdf
June 20, 2012 - Factors predicting change in hospital safety climate and
capability in a multi-site patient safety collaborative: a
longitudinal survey study.
June 20, 2012
Benn J, Burnett S, Parand A, et al. Factors predicting change in hospital safety climate and capability in a
multi-site patient safety collaborative: a longit…
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psnet.ahrq.gov/node/47771/psn-pdf
April 24, 2019 - The impact of errors on healthcare professionals in the
critical care setting.
April 24, 2019
Kaur AP, Levinson AT, Monteiro JFG, et al. The impact of errors on healthcare professionals in the critical
care setting. J Crit Care. 2019;52:16-21. doi:10.1016/j.jcrc.2019.03.001.
https://psnet.ahrq.gov/issue/impact-err…
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psnet.ahrq.gov/node/836858/psn-pdf
April 06, 2022 - Psychological safety during the test of new work
processes in an emergency department.
April 6, 2022
Dieckmann P, Tulloch S, Dalgaard AE, et al. Psychological safety during the test of new work processes in
an emergency department. BMC Health Serv Res. 2022;22(1):307. doi:10.1186/s12913-022-07687-y.
https://psnet.…
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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.…
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psnet.ahrq.gov/node/841155/psn-pdf
February 02, 2020 - Understanding unwarranted variation in clinical practice:
a focus on network effects, reflective medicine and
learning health systems.
February 2, 2020
Atsma F, Elwyn G, Westert GP. Understanding unwarranted variation in clinical practice: a focus on
network effects, reflective medicine and learning health systems…
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psnet.ahrq.gov/node/73596/psn-pdf
August 11, 2021 - Empowering Patients and Supporting Health Care
Providers—New Avenues for High Quality Care and
Safety.
August 11, 2021
Rimondini M, Busch IM, eds. Int J Environ Res Public Health. 2021;18.
https://psnet.ahrq.gov/issue/empowering-patients-and-supporting-health-care-providers-new-avenues-high-
quality-care-and…
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psnet.ahrq.gov/node/43294/psn-pdf
April 25, 2016 - The right and wrong way to talk to patients about adverse
events.
April 25, 2016
Beaulieu-Volk D. The right and wrong way to talk to patients about adverse events. Medical economics.
2014;91(11):52-5.
https://psnet.ahrq.gov/issue/right-and-wrong-way-talk-patients-about-adverse-events
Apology laws have been explor…
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psnet.ahrq.gov/node/43412/psn-pdf
May 28, 2015 - An observational study of how patients are identified
before medication administrations in medical and surgical
wards.
May 28, 2015
Härkänen M, Kervinen M, Ahonen J, et al. An observational study of how patients are identified before
medication administrations in medical and surgical wards. Nurs Health Sci. 2015;1…
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psnet.ahrq.gov/node/837866/psn-pdf
August 17, 2022 - A System in Need of Repair: Addressing Organizational
Failures of the U.S.’s Organ Procurement and
Transplantation Network.
August 17, 2022
US Senate Finance Committee. 117th Cong (2021-2022). August 3, 2022.
https://psnet.ahrq.gov/issue/system-need-repair-addressing-organizational-failures-uss-organ-
procurement…