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psnet.ahrq.gov/node/38904/psn-pdf
September 02, 2009 - Litigation related to inadequate anaesthesia: an analysis
of claims against the NHS in England 1995-2007.
September 2, 2009
Mihai R, Scott SD, Cook TM. Litigation related to inadequate anaesthesia: an analysis of claims against the
NHS in England 1995-2007. Anaesthesia. 2009;64(8):829-35. doi:10.1111/j.1365-2044.20…
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psnet.ahrq.gov/node/33930/psn-pdf
June 23, 2015 - Adverse respiratory events in anesthesia: a closed claims
analysis.
June 23, 2015
Caplan RA, Posner KL, Ward RJ, et al. Adverse respiratory events in anesthesia: a closed claims analysis.
Anesthesiology. 1990;72(5):828-33.
https://psnet.ahrq.gov/issue/adverse-respiratory-events-anesthesia-closed-claims-analysis
A…
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psnet.ahrq.gov/node/866864/psn-pdf
October 02, 2024 - Patient safety in actioning and communicating blood test
results in primary care: a UK wide audit using the Primary
Care Academic CollaboraTive (PACT).
October 2, 2024
Watson J, Duncan P, Burrell A, et al. Patient safety in actioning and communicating blood test results in
primary care: a UK wide audit using the P…
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psnet.ahrq.gov/issue/some-unintended-consequences-information-technology-health-care-nature-patient-care
November 18, 2020 - February 1, 2023
Orders on file but no labs drawn: investigation of machine and human
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psnet.ahrq.gov/node/43906/psn-pdf
May 13, 2015 - Nursing handovers as resilient points of care: linking
handover strategies to treatment errors in the patient care
in the following shift.
May 13, 2015
Drach-Zahavy A, Hadid N. Nursing handovers as resilient points of care: linking handover strategies to
treatment errors in the patient care in the following shift.…
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psnet.ahrq.gov/node/37168/psn-pdf
February 03, 2011 - Physician scores on a national clinical skills examination
as predictors of complaints to medical regulatory
authorities.
February 3, 2011
Tamblyn R, Abrahamowicz M, Dauphinee D, et al. Physician scores on a national clinical skills examination
as predictors of complaints to medical regulatory authorities. JAMA. 2…
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psnet.ahrq.gov/node/39485/psn-pdf
November 23, 2016 - A human factors and survey methodology-based design
of a web-based adverse event reporting system for
families.
November 23, 2016
Daniels JP, King AD, Cochrane D, et al. A human factors and survey methodology-based design of a web-
based adverse event reporting system for families. Int J Med Inform. 2010;79(5):339…
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psnet.ahrq.gov/node/867985/psn-pdf
January 01, 2025 - Suicide Prevention
March 25, 2025
Boudreaux E, Gale B, Mossburg SE. Suicide Prevention. PSNet [internet]. 20024.
https://psnet.ahrq.gov/perspective/suicide-prevention
Introduction
Suicide is one of the leading causes of death in the United States, accounting for nearly 50,000 deaths in
2022, a 36% rise since 2000…
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psnet.ahrq.gov/node/49744/psn-pdf
October 01, 2015 - The Risks of Absent Interoperability: Medication-Induced
Hemolysis in a Patient With a Known Allergy
October 1, 2015
Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known
Allergy. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/risks-absent-interoperability-me…
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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/36515/psn-pdf
May 27, 2011 - Nurses' perceptions of causes of medication errors and
barriers to reporting.
May 27, 2011
Ulanimo VM, O'Leary-Kelley C, Connolly PM. Nurses' perceptions of causes of medication errors and
barriers to reporting. J Nurs Care Qual. 2007;22(1):28-33.
https://psnet.ahrq.gov/issue/nurses-perceptions-causes-medication-e…
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psnet.ahrq.gov/node/38157/psn-pdf
October 22, 2008 - Contributing factors identified by hospital incident report
narratives.
October 22, 2008
Nuckols TK, Bell DS, Paddock SM, et al. Contributing factors identified by hospital incident report
narratives. Qual Saf Health Care. 2008;17(5):368-72. doi:10.1136/qshc.2007.023721.
https://psnet.ahrq.gov/issue/contributing-f…
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psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - The Consequences of Miscommunication Regarding a
Possible Artifact
June 30, 2021
Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
Disclosure of Relevant Financial Relationships…
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psnet.ahrq.gov/node/35907/psn-pdf
October 03, 2017 - Transparent and open discussion of errors does not
increase malpractice risk in trauma patients.
October 3, 2017
Stewart RM, Corneille MG, Johnston J, et al. Transparent and open discussion of errors does not increase
malpractice risk in trauma patients. Ann Surg. 2006;243(5):645-9; discussion 649-51.
https://psne…
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psnet.ahrq.gov/issue/types-unintended-consequences-related-computerized-provider-order-entry
February 18, 2011 - April 29, 2018
Orders on file but no labs drawn: investigation of machine and human errors
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-38
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR.
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psnet.ahrq.gov/node/41066/psn-pdf
October 16, 2012 - Hospital Incident Reporting Systems Do Not Capture Most
Patient Harm.
October 16, 2012
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector
General; January 2012. Report No. OEI-06-09-00091.
https://psnet.ahrq.gov/issue/hospital-incident-reporting-systems-do-not-capture-…
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psnet.ahrq.gov/node/34804/psn-pdf
January 05, 2017 - Incident reporting system does not detect adverse drug
events: a problem for quality improvement.
January 5, 2017
Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events:
a problem for quality improvement. Jt Comm J Qual Improv. 1995;21(10):541-8.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/38366/psn-pdf
January 28, 2009 - Benchmarking surgical incident reports using a database
and a triage system to reduce adverse outcomes.
January 28, 2009
Antonacci AC, Lam S, Lavarias V, et al. Benchmarking surgical incident reports using a database and a
triage system to reduce adverse outcomes. Arch Surg. 2008;143(12):1192-7.
doi:10.1001/archsu…
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psnet.ahrq.gov/node/33759/psn-pdf
October 01, 2012 - Promising Areas for Patient Safety Research
December 1, 2003
Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. PSNet [internet]. 2003.
https://psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
Perspective
Setting a Course for Patient Safety Research
Although patient safety…