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psnet.ahrq.gov/issue/wrong-side-thoracentesis-lessons-learned-root-cause-analysis
July 16, 2015 - Study
Wrong-side thoracentesis: lessons learned from root cause analysis.
Citation Text:
Miller K, Mims M, Paull DE, et al. Wrong-side thoracentesis: lessons learned from root cause analysis. JAMA Surg. 2014;149(8):774-9. doi:10.1001/jamasurg.2014.146.
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psnet.ahrq.gov/issue/analysis-reported-suicide-safety-events-among-veterans-who-received-treatment-through
August 21, 2019 - Study
Analysis of reported suicide safety events among veterans who received treatment through Department of Veterans Affairs-contracted community care.
Citation Text:
Riblet NB, Soncrant C, Mills PD, et al. Analysis of reported suicide safety events among veterans who received treatment…
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psnet.ahrq.gov/issue/adverse-patient-safety-events-during-covid-epidemic
May 03, 2023 - Study
Adverse patient safety events during the COVID epidemic.
Citation Text:
Yackel EE, Knowles RS, Jones CM, et al. Adverse patient safety events during the COVID epidemic. J Patient Saf. 2023;19(5):340-345. doi:10.1097/pts.0000000000001129.
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psnet.ahrq.gov/issue/making-health-care-safer-critical-analysis-patient-safety-practices
July 27, 2018 - Book/Report
Making Health Care Safer: A Critical Analysis of Patient Safety Practices.
Citation Text:
Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Shojania KG, Duncan BW, McDonald KM, et al, eds. Rockville, MD: Agency for Healthcare Research and Quality; J…
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psnet.ahrq.gov/issue/telemedicine-medical-examination-tool-during-covid-19-emergency-experience-onco-haematology
September 15, 2021 - Study
Telemedicine as a medical examination tool during the Covid-19 emergency: the experience of the onco-haematology center of Tor Vergata Hospital in Rome.
Citation Text:
Postorino M, Treglia M, Giammatteo J, et al. Telemedicine as a medical examination tool during the Covid-19 emerge…
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psnet.ahrq.gov/issue/wrong-patient-blood-transfusion-error-leveraging-technology-overcome-human-error
December 09, 2020 - Study
Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.
Citation Text:
Hensley NB, Koch CG, Pronovost P, et al. Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Int…
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psnet.ahrq.gov/issue/why-do-systems-responding-concerns-and-complaints-so-often-fail-patients-families-and
June 16, 2021 - Study
Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff?
Citation Text:
Martin GP, Chew S, Dixon-Woods M. Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? A qualita…
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psnet.ahrq.gov/issue/potentially-inappropriate-prescribing-among-older-persons-meta-analysis-observational-studies
May 27, 2020 - Review
Emerging Classic
Potentially inappropriate prescribing among older persons: a meta-analysis of observational studies.
Citation Text:
Liew TM, Lee CS, Shawn KLG, et al. Potentially Inappropriate Prescribing Among Older Persons: A Meta-Analysis of Observati…
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psnet.ahrq.gov/issue/prevalence-and-impact-potentially-inappropriate-prescribing-among-older-persons-primary-care
July 24, 2019 - Review
Emerging Classic
The prevalence and impact of potentially inappropriate prescribing among older persons in primary care settings: multilevel meta-analysis.
Citation Text:
Liew TM, Lee CS, Goh SKL, et al. The prevalence and impact of potentially inappropri…
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psnet.ahrq.gov/issue/nursing-strategies-safeguard-covid-19-patients-harm-intensive-care-unit
July 31, 2013 - Commentary
Nursing strategies to safeguard COVID-19 patients from harm in the intensive care unit.
Citation Text:
Shiner D, Bock B, Simpson C, et al. Nursing strategies to safeguard COVID-19 patients from harm in the intensive care unit. Crit Care Nurs Q. 2021;45(1):13-21. doi:10.1097/cn…
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psnet.ahrq.gov/issue/perception-patient-safety-climate-health-professionals-during-covid-19-pandemic-international
February 15, 2023 - Study
The perception of the patient safety climate by health professionals during the COVID-19 pandemic-international research.
Citation Text:
Kosydar-Bochenek J, Krupa S, Religa D, et al. The Perception of the Patient Safety Climate by Health Professionals during the COVID-19 Pandemic—I…
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psnet.ahrq.gov/node/50647/psn-pdf
November 06, 2019 - ‘Fear of falling’: how hospitals do even more harm by
keeping patients in bed.
November 6, 2019
Bailey M. Kaiser Health News. October 17, 2019.
https://psnet.ahrq.gov/issue/fear-falling-how-hospitals-do-even-more-harm-keeping-patients-bed
Patient falls with harm are a common sentinel event. This news story discuss…
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psnet.ahrq.gov/node/837863/psn-pdf
August 17, 2022 - The Nursing Home Expert Panel’s Falls Investigation
Guide Toolkit: How-To Guide.
August 17, 2022
Portland, OR: Oregon Patient Safety Commission; 2022.
https://psnet.ahrq.gov/issue/nursing-home-expert-panels-falls-investigation-guide-toolkit-how-guide
Patient falls are common sentinel events. The latest revis…
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psnet.ahrq.gov/node/50862/psn-pdf
February 05, 2020 - Assessment of nursing home reporting of major injury
falls for quality measurement on Nursing Home Compare.
February 5, 2020
Sanghavi P, Pan S, Caudry D. Assessment of nursing home reporting of major injury falls for quality
measurement on nursing home compare. Health Serv Res. 2020;55(2):201-210. doi:10.1111/1475-…
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psnet.ahrq.gov/node/38715/psn-pdf
February 17, 2011 - Medicare nonpayment, hospital falls, and unintended
consequences.
February 17, 2011
Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. N
Engl J Med. 2009;360(23):2390-3. doi:10.1056/NEJMp0900963.
https://psnet.ahrq.gov/issue/medicare-nonpayment-hospital-falls-and-uni…
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psnet.ahrq.gov/node/37792/psn-pdf
February 15, 2011 - Exploring organizational context and structure as
predictors of medication errors and patient falls.
February 15, 2011
Mark BA, Hughes LC, Belyea M, et al. Exploring Organizational Context and Structure as Predictors of
Medication Errors and Patient Falls. J Patient Saf. 2008;4(2). doi:10.1097/pts.0b013e3181695671.…
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psnet.ahrq.gov/node/37518/psn-pdf
March 13, 2008 - Innovation in patient safety: a new task design in
reducing patient falls.
March 13, 2008
Tzeng H-M, Yin C-Y. Innovation in patient safety: a new task design in reducing patient falls. J Nurs Care
Qual. 2008;23(1):34-42. doi:10.1097/01.NCQ.0000303803.07457.e5.
https://psnet.ahrq.gov/issue/innovation-patient-safety…
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psnet.ahrq.gov/node/40454/psn-pdf
June 01, 2012 - Influence of unit-level staffing on medication errors and
falls in military hospitals.
June 1, 2012
Breckenridge-Sproat S, Johantgen M, Patrician PA. Influence of unit-level staffing on medication errors and
falls in military hospitals. West J Nurs Res. 2012;34(4):455-74. doi:10.1177/0193945911407090.
https://psne…
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psnet.ahrq.gov/node/47508/psn-pdf
October 24, 2018 - Root cause analysis of reported patient falls in ORs in the
Veterans Health Administration.
October 24, 2018
Soncrant CM, Warner LJ, Neily J, et al. Root Cause Analysis of Reported Patient Falls in ORs in the
Veterans Health Administration. AORN J. 2018;108(4):386-397. doi:10.1002/aorn.12372.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/39255/psn-pdf
February 02, 2011 - The patient who falls: "It's always a trade-off."
February 2, 2011
Tinetti ME, Kumar C. The patient who falls: "It's always a trade-off". JAMA. 2010;303(3):258-66.
doi:10.1001/jama.2009.2024.
https://psnet.ahrq.gov/issue/patient-who-falls-its-always-trade
Through a case study, this article reviews evidence on risk…