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psnet.ahrq.gov/node/60039/psn-pdf
March 11, 2020 - A 25-year-old teacher died after waiting hours at the ER.
She's not the only one who saw delays.
March 11, 2020
Linnane R, Diedrich J. Milwaukee Journal Sentinel. February 25, 2020.
https://psnet.ahrq.gov/issue/25-year-old-teacher-died-after-waiting-hours-er-shes-not-only-one-who-saw-
delays
Delays in emergency r…
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psnet.ahrq.gov/node/36476/psn-pdf
December 14, 2009 - 10 Patient Safety Tips for Hospitals.
December 14, 2009
Rockville, MD: Agency for Healthcare Research and Quality; December 2009. AHRQ Publication No. 10-
M008.
https://psnet.ahrq.gov/issue/10-patient-safety-tips-hospitals
This tip sheet provides 10 practical steps hospitals can undertake to improve patient safety…
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psnet.ahrq.gov/node/47744/psn-pdf
July 19, 2019 - A qualitative positive deviance study to explore
exceptionally safe care on medical wards for older
people.
July 19, 2019
Baxter R, Taylor N, Kellar I, et al. A qualitative positive deviance study to explore exceptionally safe care on
medical wards for older people. BMJ Qual Saf. 2019;28(8):618-626. doi:10.1136/bm…
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psnet.ahrq.gov/node/837962/psn-pdf
August 31, 2022 - Positive approaches to safety: learning from what we do
well.
August 31, 2022
Plunkett A, Plunkett E. Positive approaches to safety: learning from what we do well. Paediatr Anaesth.
2022;32(11):1223-1229. doi:10.1111/pan.14509.
https://psnet.ahrq.gov/issue/positive-approaches-safety-learning-what-we-do-well
Safet…
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psnet.ahrq.gov/node/43989/psn-pdf
March 18, 2015 - Application of a trigger tool in near real time to inform
quality improvement activities: a prospective study in a
general medicine ward.
March 18, 2015
Wong BM, Dyal S, Etchells E, et al. Application of a trigger tool in near real time to inform quality
improvement activities: a prospective study in a general med…
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psnet.ahrq.gov/node/73299/psn-pdf
May 19, 2021 - More can be done to alleviate errors associated with
pharmaceutical product labeling and packaging.
May 19, 2021
ISMP Medication Safety Alert! Acute Care Edition. May 6, 2021;26(9):1-4.
https://psnet.ahrq.gov/issue/more-can-be-done-alleviate-errors-associated-pharmaceutical-product-
labeling-and-packaging
Look-al…
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psnet.ahrq.gov/node/839823/psn-pdf
November 09, 2022 - Prescribing decision making by medical residents on
night shifts: a qualitative study.
November 9, 2022
Lauffenburger JC, Coll MD, Kim E, et al. Prescribing decision making by medical residents on night shifts: a
qualitative study. Med Educ. 2022;56(10):1032-1041. doi:10.1111/medu.14845.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/43179/psn-pdf
July 28, 2014 - The effect of the electronic transmission of prescriptions
on dispensing errors and prescription enhancements
made in English community pharmacies: a naturalistic
stepped wedge study.
July 28, 2014
Franklin BD, Reynolds M, Sadler S, et al. The effect of the electronic transmission of prescriptions on
dispensing e…
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psnet.ahrq.gov/node/45029/psn-pdf
April 20, 2016 - Threats to safety during sedation outside of the operating
room and the death of Michael Jackson.
April 20, 2016
Webster CS, Mason KP, Shafer SL. Threats to safety during sedation outside of the operating room and
the death of Michael Jackson. Curr Opin Anaesthesiol. 2016;29 Suppl 1:S36-47.
doi:10.1097/ACO.0000000…
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psnet.ahrq.gov/node/862152/psn-pdf
February 07, 2024 - Risk identification and prediction of complaints and
misconduct against health practitioners: a scoping
review.
February 7, 2024
Wang Y, Ram SS, Scahill S. Risk identification and prediction of complaints and misconduct against health
practitioners: a scoping review. Int J Qual Health Care. 2024;36(1):mzad114. doi…
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psnet.ahrq.gov/node/46719/psn-pdf
December 20, 2017 - Frustrated with your EHR? Don't blame your
vendor—safety is a shared responsibility.
December 20, 2017
Singh H, Sittig DF. NEJM Catalyst. December 7, 2017.
https://psnet.ahrq.gov/issue/frustrated-your-ehr-dont-blame-your-vendor-safety-shared-responsibility
The promise of health information technology has yet to be…
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psnet.ahrq.gov/node/72729/psn-pdf
February 10, 2021 - Exploring the theory, barriers and enablers for patient and
public involvement across health, social care and patient
safety: a systematic review of reviews.
February 10, 2021
Ocloo J, Garfield S, Franklin BD, et al. Exploring the theory, barriers and enablers for patient and public
involvement across health, soci…
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psnet.ahrq.gov/node/44716/psn-pdf
April 15, 2016 - An integrative review of patient safety in studies on the
care and safety of patients with communication
disabilities in hospital.
April 15, 2016
Hemsley B, Georgiou A, Hill S, et al. An integrative review of patient safety in studies on the care and
safety of patients with communication disabilities in hospital. …
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psnet.ahrq.gov/node/38091/psn-pdf
February 18, 2011 - Questionable hospital chart documentation practices by
physicians.
February 18, 2011
Sharma R, Kostis WJ, Wilson AC, et al. Questionable hospital chart documentation practices by
physicians. J Gen Intern Med. 2008;23(11):1865-70. doi:10.1007/s11606-008-0750-6.
https://psnet.ahrq.gov/issue/questionable-hospital-cha…
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psnet.ahrq.gov/node/43721/psn-pdf
December 03, 2014 - Predicting potential postdischarge adverse drug events
and 30-day unplanned hospital readmissions from
medication regimen complexity.
December 3, 2014
Schoonover H, Corbett CF, Weeks DL, et al. Predicting potential postdischarge adverse drug events and
30-day unplanned hospital readmissions from medication regimen…
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psnet.ahrq.gov/node/60927/psn-pdf
September 16, 2020 - Amid COVID-19, discipline against bad doctors plummets;
more medical errors may slip through cracks.
September 16, 2020
O'Donnell J. USA Today. September 8, 2020
https://psnet.ahrq.gov/issue/amid-covid-19-discipline-against-bad-doctors-plummets-more-medical-errors-
may-slip-through
Management and clinical functio…
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psnet.ahrq.gov/node/852797/psn-pdf
August 23, 2023 - Anaesthesia and patient safety in the socio-technical
operating theatre: a narrative review spanning a century.
August 23, 2023
Webster CS, Mahajan R, Weller JM. Anaesthesia and patient safety in the socio-technical operating
theatre: a narrative review spanning a century. Br J Anaesth. 2023;131(2):397-406.
doi:10…
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psnet.ahrq.gov/node/36552/psn-pdf
January 12, 2011 - Toward learning from patient safety reporting systems.
January 12, 2011
Pronovost P, Thompson DA, Holzmueller CG, et al. Toward learning from patient safety reporting systems.
J Crit Care. 2006;21(4):305-15.
https://psnet.ahrq.gov/issue/toward-learning-patient-safety-reporting-systems
This study reports the initia…
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psnet.ahrq.gov/node/866593/psn-pdf
August 28, 2024 - Navigating the complex terrain of patient safety:
challenges, strategies, and the importance of ongoing
evaluation and knowledge sharing.
August 28, 2024
Macleod H, Greenfield D. Navigating the complex terrain of patient safety: challenges, strategies, and the
importance of ongoing evaluation and knowledge sharing…
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psnet.ahrq.gov/node/45879/psn-pdf
July 02, 2017 - A hybrid methodology for modeling risk of adverse
events in complex health-care settings.
July 2, 2017
Kazemi R, Mosleh A, Dierks M. A Hybrid Methodology for Modeling Risk of Adverse Events in Complex
Health-Care Settings. Risk Anal. 2017;37(3):421-440. doi:10.1111/risa.12702.
https://psnet.ahrq.gov/issue/hybrid-m…