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psnet.ahrq.gov/node/841150/psn-pdf
December 07, 2022 - Quality improvement as a primary approach to change in
healthcare: a precarious, self-limiting choice?
December 7, 2022
Mandel KE, Cady SH. Quality improvement as a primary approach to change in healthcare: a precarious,
self-limiting choice? BMJ Qual Saf. 2022;31(12):860-866. doi:10.1136/bmjqs-2021-014447.
https:…
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psnet.ahrq.gov/node/73449/psn-pdf
June 30, 2021 - Adverse events and emergency department opioid
prescriptions in adolescents.
June 30, 2021
Worsham CM, Woo J, Jena AB, et al. Adverse events and emergency department opioid prescriptions in
adolescents. Health Aff (Millwood). 2021;40(6):970-978. doi:10.1377/hlthaff.2020.01762.
https://psnet.ahrq.gov/issue/adverse-…
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psnet.ahrq.gov/node/837023/psn-pdf
May 04, 2022 - Examining the effect of quality improvement initiatives on
decreasing racial disparities in maternal morbidity.
May 4, 2022
Davidson C, Denning S, Thorp K, et al. Examining the effect of quality improvement initiatives on
decreasing racial disparities in maternal morbidity. BMJ Qual Saf. 2022;31(9):670-678. doi:10.…
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psnet.ahrq.gov/node/867691/psn-pdf
March 05, 2025 - Surgeon perception and attitude towards the moral
imperative of institutionally addressing second-victim
syndrome in surgery.
March 5, 2025
Hsiao L-H, Kopar PK. Surgeon perception and attitude towards the moral imperative of institutionally
addressing second-victim syndrome in surgery. J Am Coll Surg. 2025;240(2):…
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psnet.ahrq.gov/node/73281/psn-pdf
May 19, 2021 - Measuring safety in older adult care homes: a scoping
review of the international literature.
May 19, 2021
Rand S, Smith N, Jones K, et al. Measuring safety in older adult care homes: a scoping review of the
international literature. BMJ Open. 2021;11(3):e043206. doi:10.1136/bmjopen-2020-043206.
https://psnet.ahrq…
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psnet.ahrq.gov/node/34735/psn-pdf
June 16, 2014 - An Organisation with a Memory: Report of an Expert
Group on Learning from Adverse Events in the NHS
Chaired by the Chief Medical Officer.
June 16, 2014
Donaldson L. London, UK: The Stationery Office, 2000.
https://psnet.ahrq.gov/issue/organisation-memory-report-expert-group-learning-adverse-events-nhs-
chaired-ch…
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psnet.ahrq.gov/node/34651/psn-pdf
March 04, 2011 - Incidence and types of preventable adverse events in
elderly patients: population based review of medical
records.
March 4, 2011
Thomas EJ, Brennan TA. Incidence and types of preventable adverse events in elderly patients: population
based review of medical records. BMJ. 2000;320(7237):741-4.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/837859/psn-pdf
August 17, 2022 - The barriers and enhancers to trust in a just culture in
hospital settings: a systematic review.
August 17, 2022
van Marum S, Verhoeven D, de Rooy D. The barriers and enhancers to trust in a just culture in hospital
settings: a systematic review. J Patient Saf. 2022;18(7):e1067-e1075. doi:10.1097/pts.00000000000010…
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psnet.ahrq.gov/node/46886/psn-pdf
August 01, 2018 - Support strategies for health care professionals who are
second victims.
August 1, 2018
Hauk L. Support strategies for health care professionals who are second victims. AORN J. 2018;107(6):P7-
P9. doi:10.1002/aorn.12291.
https://psnet.ahrq.gov/issue/support-strategies-health-care-professionals-who-are-second-victi…
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psnet.ahrq.gov/node/36434/psn-pdf
February 18, 2011 - Protocol-based computer reminders, the quality of care
and the non-perfectability of man.
February 18, 2011
McDonald CJ. Protocol-based computer reminders, the quality of care and the non-perfectability of man. N
Engl J Med. 1976;295(24):1351-5.
https://psnet.ahrq.gov/issue/protocol-based-computer-reminders-qualit…
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psnet.ahrq.gov/node/47883/psn-pdf
May 29, 2019 - Patient Safety in Obstetrics and Gynecology.
May 29, 2019
Gluck PA, ed. Obstet Gynecol Clin North Am. 2019;46:H1-H8, 199-398.
https://psnet.ahrq.gov/issue/patient-safety-obstetrics-and-gynecology
Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. Articles in
this speci…
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psnet.ahrq.gov/node/43496/psn-pdf
November 01, 2016 - Designing and Delivering Whole-Person Transitional
Care: Hospital Guide to Reducing Medicaid
Readmissions.
November 1, 2016
Boutwell A, Bourgoin A , Maxwell J, et al. Rockville, MD: Agency for Healthcare Research and Quality;
September 2016. AHRQ Publication No. 16-0047-EF.
https://psnet.ahrq.gov/issue/designing-…
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psnet.ahrq.gov/node/852799/psn-pdf
June 11, 2019 - The Giving Voice to Mothers study: inequity and
mistreatment during pregnancy and childbirth in the
United States.
June 11, 2019
Vedam S, Stoll K, Taiwo TK, et al. The Giving Voice to Mothers study: inequity and mistreatment during
pregnancy and childbirth in the United States. Reprod Health. 2019;16(1):77. doi:10…
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psnet.ahrq.gov/node/845636/psn-pdf
March 08, 2023 - The effects of leadership for self-worth, inclusion, trust,
and psychological safety on medical error reporting.
March 8, 2023
Brimhall KC, Tsai C-Y, Eckardt R, et al. The effects of leadership for self-worth, inclusion, trust, and
psychological safety on medical error reporting. Health Care Manage Rev. 2023;48(2):…
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psnet.ahrq.gov/node/46101/psn-pdf
January 01, 2018 - Factors associated with barcode medication
administration technology that contribute to patient
safety: an integrative review.
December 19, 2017
Strudwick G, Reisdorfer E, Warnock C, et al. Factors Associated With Barcode Medication Administration
Technology That Contribute to Patient Safety: An Integrative Review…
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psnet.ahrq.gov/node/837635/psn-pdf
July 06, 2022 - Family safety reporting in medically complex children:
parent, staff, and leader perspectives.
July 6, 2022
Khan A, Baird JD, Kelly MM, et al. Family safety reporting in medically complex children: parent, staff, and
leader perspectives. Pediatrics. 2022;149(6):e2021053913. doi:10.1542/peds.2021-053913.
https://ps…
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psnet.ahrq.gov/node/861767/psn-pdf
January 31, 2024 - Health literacy-informed communication to reduce
discharge medication errors in hospitalized children: a
randomized clinical trial.
January 31, 2024
Carroll AR, Johnson JA, Stassun JC, et al. Health literacy-informed communication to reduce discharge
medication errors in hospitalized children: a randomized clinica…
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psnet.ahrq.gov/node/836990/psn-pdf
April 27, 2022 - Anatomy of a cyberattack: part 4: quality assurance and
error reduction, billing and compliance, transition to
uptime.
April 27, 2022
Frisch NK, Gibson PC, Stowman AM, et al. Anatomy of a cyberattack: part 4: quality assurance and error
reduction, billing and compliance, transition to uptime. Am J Emerg Med. 2022;…
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psnet.ahrq.gov/node/46118/psn-pdf
December 20, 2017 - Predictors of in-hospital postoperative opioid overdose
after major elective operations: a nationally
representative cohort study.
December 20, 2017
Cauley CE, Anderson G, Haynes AB, et al. Predictors of In-hospital Postoperative Opioid Overdose After
Major Elective Operations: A Nationally Representative Cohort S…
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psnet.ahrq.gov/node/72483/psn-pdf
November 18, 2020 - ACGME Summary Report: The Pursuing Excellence
Pathway Leaders Patient Safety Collaborative.
November 18, 2020
Passiment M, Wagner R, Weiss KB for the Pursuing Excellence in Clinical Learning Environments:
Pathway Leaders Patient Safety Collaborative. Chicago, IL: Accreditation Council for Graduate Medical
Educatio…