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psnet.ahrq.gov/node/853970/psn-pdf
September 27, 2023 - Clinical triggers and vital signs influencing crisis
acknowledgment and calls for help by anesthesiologists:
a simulation-based observational study.
September 27, 2023
Matern LH, Gardner R, Rudolph JW, et al. Clinical triggers and vital signs influencing crisis
acknowledgment and calls for help by anesthesiologist…
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psnet.ahrq.gov/node/836718/psn-pdf
March 09, 2022 - Systems engineering analysis of diagnostic referral
closed-loop processes.
March 9, 2022
Nehls N, Yap TS, Salant T, et al. Systems engineering analysis of diagnostic referral closed-loop
processes. BMJ Open Qual. 2021;10(4):e001603. doi:10.1136/bmjoq-2021-001603.
https://psnet.ahrq.gov/issue/systems-engineering-an…
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psnet.ahrq.gov/node/34662/psn-pdf
December 24, 2008 - User's manual for the IOM's 'Quality Chasm' report.
December 24, 2008
Berwick DM. A user's manual for the IOM's 'Quality Chasm' report. Health Aff (Millwood). 2002;21(3):80-90.
https://psnet.ahrq.gov/issue/users-manual-ioms-quality-chasm-report
Fifteen months after releasing its report on patient safety (To Err Is …
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psnet.ahrq.gov/node/852464/psn-pdf
August 16, 2023 - Notice of Intent to Publish Funding Opportunity
Announcements to Understand and Improve Diagnostic
Safety in Ambulatory Care.
August 16, 2023
Rockville, MD: Agency for Research and Quality; July 27, 2023. Notice Number NOT-HS-23-018.
https://psnet.ahrq.gov/issue/notice-intent-publish-funding-opportunity-announceme…
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psnet.ahrq.gov/node/50424/psn-pdf
September 04, 2019 - From box ticking to the black box: the evolution of
operating room safety.
September 4, 2019
Goldenberg MG, Elterman D. From box ticking to the black box: the evolution of operating room safety.
World J Urol. 2019;38(6):1369-1372. doi:10.1007/s00345-019-02886-5.
https://psnet.ahrq.gov/issue/box-ticking-black-box-e…
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psnet.ahrq.gov/node/866247/psn-pdf
July 10, 2024 - Analysis of critical incident reports using natural
language processing.
July 10, 2024
Denecke K, Paula H. Analysis of critical incident reports using natural language processing. Stud Health
Technol Inform. 2024;313:1-6. doi:10.3233/shti240002.
https://psnet.ahrq.gov/issue/analysis-critical-incident-reports-using…
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psnet.ahrq.gov/node/45584/psn-pdf
November 02, 2016 - Discrepancies between prescribed and actual pediatric
home parenteral nutrition solutions.
November 2, 2016
Raphael BP, Murphy M, Gura KM, et al. Discrepancies Between Prescribed and Actual Pediatric Home
Parenteral Nutrition Solutions. Nutr Clin Pract. 2016;31(5):654-658. doi:10.1177/0884533616639410.
https://psn…
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psnet.ahrq.gov/node/44290/psn-pdf
April 10, 2023 - Retained surgical sponge (gossypiboma) and other
retained surgical items: prevention and management.
April 10, 2023
Copeland AW. UpToDate. April 10, 2023.
https://psnet.ahrq.gov/issue/retained-surgical-sponge-gossypiboma-and-other-retained-surgical-items-
prevention-and
Retained surgical items are rare and potent…
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psnet.ahrq.gov/node/44677/psn-pdf
June 07, 2016 - Computerised prescribing for safer medication ordering:
still a work in progress.
June 7, 2016
Schiff G, Hickman T-TT, Volk LA, et al. Computerised prescribing for safer medication ordering: still a work
in progress. BMJ Qual Saf. 2016;25(5):315-9. doi:10.1136/bmjqs-2015-004677.
https://psnet.ahrq.gov/issue/comput…
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psnet.ahrq.gov/node/866648/psn-pdf
September 04, 2024 - ACOG Committee Statement No. 10: Racial and Ethnic
Inequities in Obstetrics and Gynecology.
September 4, 2024
ACOG Committee Statement No. 10: Racial and Ethnic Inequities in Obstetrics and Gynecology. Obstet
Gynecol. 2024;144(3):e62-e74. doi:10.1097/aog.0000000000005678.
https://psnet.ahrq.gov/issue/acog-committe…
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psnet.ahrq.gov/node/839322/psn-pdf
November 02, 2022 - A perfect storm averted: flawed systems, a dropped ball,
and cognitive biases delay a critical diagnosis.
November 2, 2022
Roberts TJ, Sellars MC, Sands JM, et al. A perfect storm averted: flawed systems, a dropped ball, and
cognitive biases delay a critical diagnosis. JCO Oncol Pract. 2022;18(12):833-839.
doi:10.…
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psnet.ahrq.gov/node/867146/psn-pdf
November 13, 2024 - Language discordance and patient care-Babel.
November 13, 2024
Huson TA. Language discordance and patient care-Babel. JAMA Intern Med. 2024;184(11):1287-1288.
doi:10.1001/jamainternmed.2024.4273.
https://psnet.ahrq.gov/issue/language-discordance-and-patient-care-babel
Equitable, safe health care is affected by myr…
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psnet.ahrq.gov/node/46175/psn-pdf
September 24, 2017 - Applying lessons from social psychology to transform the
culture of error disclosure.
September 24, 2017
Han J, LaMarra D, Vapiwala N. Applying lessons from social psychology to transform the culture of error
disclosure. Med Educ. 2017;51(10):996-1001. doi:10.1111/medu.13345.
https://psnet.ahrq.gov/issue/applying-…
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psnet.ahrq.gov/node/849123/psn-pdf
May 17, 2023 - Maximizing student potential: lessons for pharmacy
programs from the patient safety movement.
May 17, 2023
Abebe E, Bao A, Kokkinias P, et al. Maximizing student potential: lessons for pharmacy programs from the
patient safety movement. Explor Res Clin Soc Pharm. 2023;9:100216. doi:10.1016/j.rcsop.2022.100216.
htt…
-
psnet.ahrq.gov/node/46426/psn-pdf
September 28, 2017 - Toward more proactive approaches to safety in the
electronic health record era.
September 28, 2017
Sittig DF, Singh H. Toward More Proactive Approaches to Safety in the Electronic Health Record Era. Jt
Comm J Qual Patient Saf. 2017;43(10):540-547. doi:10.1016/j.jcjq.2017.06.005.
https://psnet.ahrq.gov/issue/toward…
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psnet.ahrq.gov/node/46707/psn-pdf
October 13, 2018 - Medication errors involving nursing students: a
systematic review.
October 13, 2018
Asensi-Vicente J, Jiménez-Ruiz I, Vizcaya-Moreno F. Medication Errors Involving Nursing Students: A
Systematic Review. Nurse Educ. 2018;43(5):E1-E5. doi:10.1097/NNE.0000000000000481.
https://psnet.ahrq.gov/issue/medication-errors-i…
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psnet.ahrq.gov/node/863217/psn-pdf
February 28, 2024 - Interpreting and coding causal relationships for quality
and safety using ICD-11.
February 28, 2024
Januel J-M, Southern DA, Ghali WA. Interpreting and coding causal relationships for quality and safety
using ICD-11. BMC Med Inform Decis Mak. 2023;21(Suppl 6):385. doi:10.1186/s12911-023-02363-5.
https://psnet.ahrq…
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psnet.ahrq.gov/node/865705/psn-pdf
May 01, 2024 - Healthcare team resilience during COVID-19: a qualitative
study.
May 1, 2024
Ambrose JW, Catchpole K, Evans HL, et al. Healthcare team resilience during COVID-19: a qualitative
study. BMC Health Serv Res. 2024;24(1):459. doi:10.1186/s12913-024-10895-3.
https://psnet.ahrq.gov/issue/healthcare-team-resilience-during…
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psnet.ahrq.gov/node/73524/psn-pdf
July 21, 2021 - Intravenous admixture preparation considerations, Parts
9-A and 9-B: error prevention in intravenous admixture
preparation.
July 21, 2021
Allen LV, Jr. Int J Pharm Compd. 2021;25:131-139; 222-229.
https://psnet.ahrq.gov/issue/intravenous-admixture-preparation-considerations-parts-9-and-9-b-error-
prevention-…
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psnet.ahrq.gov/node/45740/psn-pdf
January 23, 2017 - Patient perspectives on delays in diagnosis and treatment
of cancer: a qualitative analysis of free-text data.
January 23, 2017
Parsonage RK, Hiscock J, Law R-J, et al. Patient perspectives on delays in diagnosis and treatment of
cancer: a qualitative analysis of free-text data. Br J Gen Pract. 2017;67(654):e49-e56…