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psnet.ahrq.gov/node/43956/psn-pdf
January 01, 2016 - Monitoring the harm associated with use of
anticoagulants in pediatric populations through trigger-
based automated adverse-event detection.
June 21, 2015
Patregnani JT, Spaeder MC, Lemon V, et al. Monitoring the harm associated with use of anticoagulants in
pediatric populations through trigger-based automated ad…
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psnet.ahrq.gov/node/41049/psn-pdf
December 31, 2014 - Are physicians' perceptions of healthcare quality and
practice satisfaction affected by errors associated with
electronic health record use?
December 31, 2014
Love JS, Wright A, Simon SR, et al. Are physicians' perceptions of healthcare quality and practice
satisfaction affected by errors associated with electroni…
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psnet.ahrq.gov/node/41479/psn-pdf
December 21, 2014 - Surgical training, duty-hour restrictions, and implications
for meeting the Accreditation Council for Graduate
Medical Education core competencies: views of surgical
interns compared with program directors.
December 21, 2014
Antiel RM, Van Arendonk K, Reed DA, et al. Surgical training, duty-hour restrictions, and …
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psnet.ahrq.gov/node/43987/psn-pdf
March 25, 2015 - Emergency physicians' views of direct notification of
laboratory and radiology results to patients using the
internet: a multisite survey.
March 25, 2015
Callen J, Giardina TD, Singh H, et al. Emergency physicians' views of direct notification of laboratory and
radiology results to patients using the Internet: a m…
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psnet.ahrq.gov/node/43553/psn-pdf
August 28, 2017 - Analysis of adverse events associated with adult
moderate procedural sedation outside the operating
room.
August 28, 2017
Karamnov S, Sarkisian N, Grammer R, et al. Analysis of Adverse Events Associated With Adult Moderate
Procedural Sedation Outside the Operating Room. J Patient Saf. 2014;13(3):111-121.
doi:10.1…
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psnet.ahrq.gov/node/45255/psn-pdf
January 23, 2017 - Provider risk factors for medication administration error
alerts: analyses of a large-scale closed-loop medication
administration system using RFID and barcode.
January 23, 2017
Hwang Y, Yoon D, Ahn EK, et al. Provider risk factors for medication administration error alerts: analyses
of a large-scale closed-loop m…
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psnet.ahrq.gov/node/43803/psn-pdf
January 29, 2015 - Creating a high-reliability health care system: improving
performance on core processes of care at Johns Hopkins
Medicine.
January 29, 2015
Pronovost P, Armstrong M, Demski R, et al. Creating a high-reliability health care system: improving
performance on core processes of care at Johns Hopkins Medicine. Acad Med.…
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psnet.ahrq.gov/node/46806/psn-pdf
January 01, 2020 - Examining the relationship of an all-cause harm patient
safety measure and critical performance measures at the
frontline of care.
February 28, 2018
Sammer C, Hauck L, Jones C, et al. Examining the Relationship of an All-Cause Harm Patient Safety
Measure and Critical Performance Measures at the Frontline of Care. …
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psnet.ahrq.gov/node/40946/psn-pdf
January 19, 2012 - Effects of a multicentre teamwork and communication
programme on patient outcomes: results from the Triad
for Optimal Patient Safety (TOPS) project.
January 19, 2012
Auerbach AD, Sehgal NL, Blegen MA, et al. Effects of a multicentre teamwork and communication
programme on patient outcomes: results from the Triad f…
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psnet.ahrq.gov/node/41212/psn-pdf
March 14, 2012 - A comprehensive overview of medical error in hospitals
using incident-reporting systems, patient complaints and
chart review of inpatient deaths.
March 14, 2012
de Feijter JM, de Grave WS, Muijtjens AM, et al. A comprehensive overview of medical error in hospitals
using incident-reporting systems, patient complain…
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psnet.ahrq.gov/node/40412/psn-pdf
March 23, 2012 - Veterans Affairs initiative to prevent methicillin-resistant
Staphylococcus aureus infections.
March 23, 2012
Jain R, Kralovic SM, Evans ME, et al. Veterans Affairs initiative to prevent methicillin-resistant
Staphylococcus aureus infections. N Engl J Med. 2011;364(15):1419-30. doi:10.1056/NEJMoa1007474.
https://p…
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psnet.ahrq.gov/node/42298/psn-pdf
December 31, 2014 - Using statistical text classification to identify health
information technology incidents.
December 31, 2014
Chai KEK, Anthony S, Coiera E, et al. Using statistical text classification to identify health information
technology incidents. J Am Med Inform Assoc. 2013;20(5):980-5. doi:10.1136/amiajnl-2012-001409.
htt…
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psnet.ahrq.gov/node/41557/psn-pdf
August 01, 2012 - Signal and noise: applying a laboratory trigger tool to
identify adverse drug events among primary care
patients.
August 1, 2012
Brenner S, Detz A, Lopez A, et al. Signal and noise: applying a laboratory trigger tool to identify adverse
drug events among primary care patients. BMJ Qual Saf. 2012;21(8):670-5. doi:1…
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psnet.ahrq.gov/node/40904/psn-pdf
January 04, 2012 - Effect of illness severity and comorbidity on patient
safety and adverse events.
January 4, 2012
Naessens JM, Campbell CR, Shah ND, et al. Effect of illness severity and comorbidity on patient safety
and adverse events. Am J Med Qual. 2012;27(1):48-57. doi:10.1177/1062860611413456.
https://psnet.ahrq.gov/issue/eff…
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psnet.ahrq.gov/node/42938/psn-pdf
February 12, 2014 - Successful implementation of a unit-based quality nurse
to reduce central line-associated bloodstream infections.
February 12, 2014
Thom KA, Li S, Custer M, et al. Successful implementation of a unit-based quality nurse to reduce central
line-associated bloodstream infections. Am J Infect Control. 2014;42(2):139-43…
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psnet.ahrq.gov/node/45884/psn-pdf
January 01, 2020 - Cost–benefit analysis of a support program for nursing
staff.
December 21, 2017
Moran D, Wu AW, Connors C, et al. Cost-Benefit Analysis of a Support Program for Nursing Staff. J Patient
Saf. 2020;16(4):e250-e254. doi:10.1097/pts.0000000000000376.
https://psnet.ahrq.gov/issue/cost-benefit-analysis-support-program-n…
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psnet.ahrq.gov/node/39679/psn-pdf
January 19, 2011 - Coping with medical error: a systematic review of papers
to assess the effects of involvement in medical errors on
healthcare professionals' psychological well-being.
January 19, 2011
Sirriyeh R, Lawton R, Gardner P, et al. Coping with medical error: a systematic review of papers to assess
the effects of involveme…
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psnet.ahrq.gov/node/72586/psn-pdf
December 23, 2020 - defined by
James Reason as a knowledge gap that we fill with our own explanation, informed by our own experiences … of advanced read-back—instead of
filling in “DNR/home with hospice” knowledge gaps with their prior experiences
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psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
September 27, 2023 - Patients’ experiences of emergency hospital care following self-harm: systematic review and thematic
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psnet.ahrq.gov/node/33664/psn-pdf
March 01, 2008 - For any procedure, by virtue of doing more of them, you
get better, learn from your experiences, and