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psnet.ahrq.gov/node/37546/psn-pdf
June 14, 2011 - Effective interventions and implementation strategies to
reduce adverse drug events in the Veterans Affairs (VA)
system.
June 14, 2011
Mills PD, Neily J, Kinney LM, et al. Effective interventions and implementation strategies to reduce adverse
drug events in the Veterans Affairs (VA) system. Qual Saf Health Care. …
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www.ahrq.gov/hai/cauti-tools/cauti-icu/facil-guide/mod3-slides.html
February 01, 2023 - Module 3: Conversations Around Device Necessity
Preventing CAUTI in the ICU Setting Slide Presentation
Slide 1
AHRQ Safety Program for Reducing CAUTI in Hospitals
Preventing CAUTI in the ICU Setting
Module 3: Conversations Around Device Necessity
AHRQ Pub No. 15-0073-4-EF
September 2015
Slide 2
…
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psnet.ahrq.gov/node/45944/psn-pdf
August 15, 2018 - Orders on file but no labs drawn: investigation of machine
and human errors caused by an interface idiosyncrasy.
August 15, 2018
Schreiber R, Sittig DF, Ash JS, et al. Orders on file but no labs drawn: investigation of machine and human
errors caused by an interface idiosyncrasy. J Am Med Inform Assoc. 2017;24(5):9…
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psnet.ahrq.gov/node/36201/psn-pdf
July 10, 2008 - US and Canadian physicians' attitudes and experiences
regarding disclosing errors to patients.
July 10, 2008
Gallagher TH, Waterman AD, Garbutt J, et al. US and Canadian physicians' attitudes and experiences
regarding disclosing errors to patients. Arch Intern Med. 2006;166(15):1605-11.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/39315/psn-pdf
March 21, 2017 - Risk managers, physicians, and disclosure of harmful
medical errors.
March 21, 2017
Loren DJ, Garbutt J, Dunagan C, et al. Risk managers, physicians, and disclosure of harmful medical
errors. Jt Comm J Qual Patient Saf. 2010;36(3):101-8.
https://psnet.ahrq.gov/issue/risk-managers-physicians-and-disclosure-harmful-…
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psnet.ahrq.gov/node/40252/psn-pdf
March 02, 2011 - Older patients' understanding of emergency department
discharge information and its relationship with adverse
outcomes.
March 2, 2011
Hastings SN, Barrett A, Weinberger M, et al. Older Patients' Understanding of Emergency Department
Discharge Information and Its Relationship With Adverse Outcomes. J Patient Saf. 2…
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psnet.ahrq.gov/node/61114/psn-pdf
November 11, 2020 - A mixed-methods analysis of patient safety incidents
involving opioid substitution treatment with methadone or
buprenorphine in community-based care in England and
Wales.
November 11, 2020
Gibson R, MacLeod N, Donaldson LJ, et al. A mixed?methods analysis of patient safety incidents involving
opioid substitution …
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psnet.ahrq.gov/node/47787/psn-pdf
February 20, 2019 - How to be a very safe maternity unit: an ethnographic
study.
February 20, 2019
Liberati EG, Tarrant C, Willars J, et al. How to be a very safe maternity unit: An ethnographic study. Soc
Sci Med. 2019;223:64-72. doi:10.1016/j.socscimed.2019.01.035.
https://psnet.ahrq.gov/issue/how-be-very-safe-maternity-unit-ethnog…
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psnet.ahrq.gov/node/35572/psn-pdf
February 03, 2011 - The long road to patient safety: a status report on patient
safety systems.
February 3, 2011
Longo DR, Hewett JE, Ge B, et al. The long road to patient safety: a status report on patient safety
systems. JAMA. 2005;294(22):2858-65.
https://psnet.ahrq.gov/issue/long-road-patient-safety-status-report-patient-safety-s…
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psnet.ahrq.gov/node/44336/psn-pdf
November 03, 2015 - Reasons why physicians and advanced practice
clinicians work while sick: a mixed-methods analysis.
November 3, 2015
Szymczak JE, Smathers S, Hoegg C, et al. Reasons Why Physicians and Advanced Practice Clinicians
Work While Sick: A Mixed-Methods Analysis. JAMA Pediatr. 2015;169(9):815-821.
doi:10.1001/jamapediatri…
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psnet.ahrq.gov/node/837807/psn-pdf
August 10, 2022 - Concordance with urgent referral guidelines in patients
presenting with any of six ‘alarm’ features of possible
cancer: a retrospective cohort study using linked primary
care records.
August 10, 2022
Wiering B, Lyratzopoulos G, Hamilton W, et al. Concordance with urgent referral guidelines in patients
presenting …
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psnet.ahrq.gov/node/43474/psn-pdf
August 28, 2017 - Racial and ethnic disparities in patient safety.
August 28, 2017
Okoroh JS, Uribe EF, Weingart SN. Racial and Ethnic Disparities in Patient Safety. J Patient Saf.
2017;13(3):153-161. doi:10.1097/PTS.0000000000000133.
https://psnet.ahrq.gov/issue/racial-and-ethnic-disparities-patient-safety
Prior studies have raise…
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psnet.ahrq.gov/node/38173/psn-pdf
October 29, 2008 - The use of medical emergency teams in medical and
surgical patients: impact of patient, nurse and
organisational characteristics.
October 29, 2008
Schmid-Mazzoccoli A, Hoffman LA, Wolf GA, et al. The use of medical emergency teams in medical and
surgical patients: impact of patient, nurse and organisational charac…
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psnet.ahrq.gov/node/847716/psn-pdf
April 19, 2023 - Barriers and facilitators to improving patient safety
learning systems: a systematic review of qualitative
studies and meta-synthesis.
April 19, 2023
Mahmoud HA, Thavorn K, Mulpuru S, et al. Barriers and facilitators to improving patient safety learning
systems: a systematic review of qualitative studies and meta-…
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psnet.ahrq.gov/node/47496/psn-pdf
June 15, 2019 - Fatal flaws in clinical decision making.
June 15, 2019
Davis SS, Babidge WJ, McCulloch GAJ, et al. Fatal flaws in clinical decision making. ANZ J Surg.
2019;89(6):764-768. doi:10.1111/ans.14955.
https://psnet.ahrq.gov/issue/fatal-flaws-clinical-decision-making
Clinical decision-making is a complex process affected…
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psnet.ahrq.gov/node/36586/psn-pdf
July 08, 2008 - House staff team workload and organization effects on
patient outcomes in an academic general internal
medicine inpatient service.
July 8, 2008
Ong M, Bostrom A, Vidyarthi A, et al. House staff team workload and organization effects on patient
outcomes in an academic general internal medicine inpatient service. Ar…
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psnet.ahrq.gov/node/840153/psn-pdf
November 16, 2022 - Team debriefing in the COVID-19 pandemic: a qualitative
study of a hospital-wide clinical event debriefing program
and a novel qualitative model to analyze debriefing
content.
November 16, 2022
Welch-Horan TB, Mullan PC, Momin Z, et al. Team debriefing in the COVID-19 pandemic: a qualitative
study of a hospital-w…
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psnet.ahrq.gov/node/867087/psn-pdf
January 01, 2025 - The impact of surgical complications on obstetricians'
and gynecologists' wellbeing and coping mechanisms as
second victims.
November 6, 2024
Collings R, Potter C, Gebski V, et al. The impact of surgical complications on obstetricians’ and
gynecologists’ well-being and coping mechanisms as second victims. Am J Obs…
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psnet.ahrq.gov/node/43447/psn-pdf
November 20, 2015 - Evaluating the effect of safety culture on error reporting:
a comparison of managerial and staff perspectives.
November 20, 2015
Richter J, McAlearney AS, Pennell ML. Evaluating the effect of safety culture on error reporting: a
comparison of managerial and staff perspectives. Am J Med Qual. 2015;30(6):550-8.
doi:…
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psnet.ahrq.gov/node/849329/psn-pdf
May 24, 2023 - Interorganizational health information exchange-related
patient safety incidents: a descriptive register-based
qualitative study.
May 24, 2023
Hyvämäki P, Sneck S, Meriläinen M, et al. Interorganizational health information exchange-related patient
safety incidents: a descriptive register-based qualitative study. …