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psnet.ahrq.gov/node/37290/psn-pdf
February 15, 2011 - Medical errors involving trainees: a study of closed
malpractice claims from 5 insurers.
February 15, 2011
Singh H, Thomas EJ, Petersen L, et al. Medical errors involving trainees: a study of closed malpractice
claims from 5 insurers. Arch Intern Med. 2007;167(19):2030-6.
https://psnet.ahrq.gov/issue/medical-error…
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psnet.ahrq.gov/node/47560/psn-pdf
January 09, 2019 - Scaling safety: the South Carolina Surgical Safety
Checklist experience.
January 9, 2019
Berry WR, Edmondson L, Gibbons LR, et al. Scaling Safety: The South Carolina Surgical Safety Checklist
Experience. Health Aff (Millwood). 2018;37(11):1779-1786. doi:10.1377/hlthaff.2018.0717.
https://psnet.ahrq.gov/issue/scali…
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psnet.ahrq.gov/node/44382/psn-pdf
June 21, 2016 - Patient safety reporting: a qualitative study of thoughts
and perceptions of experts 15 years after 'To Err is
Human.'
June 21, 2016
Mitchell I, Schuster A, Smith K, et al. Patient safety incident reporting: a qualitative study of thoughts and
perceptions of experts 15 years after 'To Err is Human'. BMJ Qual Saf. …
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psnet.ahrq.gov/node/37843/psn-pdf
March 04, 2011 - Front-line staff perspectives on opportunities for
improving the safety and efficiency of hospital work
systems.
March 4, 2011
Tucker AL, Singer SJ, Hayes J, et al. Front-line staff perspectives on opportunities for improving the safety
and efficiency of hospital work systems. Health Serv Res. 2008;43(5 Pt 2):1807…
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psnet.ahrq.gov/node/37396/psn-pdf
March 28, 2012 - Risk-adjusted morbidity in teaching hospitals correlates
with reported levels of communication and collaboration
on surgical teams but not with scale measures of
teamwork climate, safety climate, or working conditions.
March 28, 2012
Davenport DL, Henderson WG, Mosca CL, et al. Risk-adjusted morbidity in teaching …
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psnet.ahrq.gov/node/46111/psn-pdf
May 17, 2017 - Implementation and adaptation of the Re-Engineered
Discharge (RED) in five California hospitals: a qualitative
research study.
May 17, 2017
Mitchell SE, Weigel GM, Laurens V, et al. Implementation and adaptation of the Re-Engineered Discharge
(RED) in five California hospitals: a qualitative research study. BMC He…
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psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
August 02, 2015 - The error in this case reflects poor clinical judgment and a fund of knowledge deficit. … Errors related to fund of knowledge deficits, inadequate clinical skills, poor clinical judgment, and … The pattern may reflect basic fund of knowledge and clinical skills deficits that are easily remediable
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psnet.ahrq.gov/node/852698/psn-pdf
August 30, 2023 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to
Increase Safety and Diagnostic Accuracy Innovation
August 30, 2023
https://psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-
diagnostic-accuracy
Summary
Addressing diagnostic errors to improve outcomes and patient safety h…
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psnet.ahrq.gov/node/837791/psn-pdf
August 05, 2022 - Patient Safety in the Ambulatory Care Setting
August 5, 2022
Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet].
2022.
https://psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
Introduction
There is no way to review the year 2021 in quality and …
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psnet.ahrq.gov/issue/recommendations-no-action-improving-effectiveness-quality-and-safety-recommendations
January 16, 2025 - Book/Report
Recommendations but no Action: Improving the Effectiveness of Quality and Safety Recommendations in Healthcare.
Citation Text:
Recommendations But No Action: Improving The Effectiveness Of Quality And Safety Recommendations In Healthcare. Dorset, UK: Health Services Safety In…
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psnet.ahrq.gov/node/46135/psn-pdf
July 11, 2017 - Two-state collaborative study of a multifaceted
intervention to decrease ventilator-associated events.
July 11, 2017
Rawat N, Yang T, Ali KJ, et al. Two-State Collaborative Study of a Multifaceted Intervention to Decrease
Ventilator-Associated Events. Crit Care Med. 2017;45(7):1208-1215.
doi:10.1097/CCM.0000000000…
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psnet.ahrq.gov/node/42819/psn-pdf
October 31, 2014 - Implementing a national program to reduce catheter-
associated urinary tract infection: a quality improvement
collaboration of state hospital associations, academic
medical centers, professional societies, and
governmental agencies.
October 31, 2014
Fakih MG, George C, Edson B, et al. Implementing a national prog…
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psnet.ahrq.gov/node/42103/psn-pdf
January 07, 2015 - Indication-based prescribing prevents wrong-patient
medication errors in computerized provider order entry
(CPOE).
January 7, 2015
Galanter W, Falck S, Burns M, et al. Indication-based prescribing prevents wrong-patient medication errors
in computerized provider order entry (CPOE). J Am Med Inform Assoc. 2013;20(3…
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psnet.ahrq.gov/node/38941/psn-pdf
November 25, 2009 - Nurse-physician communication in the long-term care
setting: perceived barriers and impact on patient safety.
November 25, 2009
Tjia J, Mazor KM, Field T, et al. Nurse-physician communication in the long-term care setting: perceived
barriers and impact on patient safety. J Patient Saf. 2009;5(3):145-152.
doi:10.10…
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psnet.ahrq.gov/node/45905/psn-pdf
December 22, 2017 - Safe practice recommendations for the use of copy-
forward with nursing flow sheets in hospital settings.
December 22, 2017
Patterson ES, Sillars DM, Staggers N, et al. Safe Practice Recommendations for the Use of Copy-Forward
with Nursing Flow Sheets in Hospital Settings. Jt Comm J Qual Patient Saf. 2017;43(8):375…
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psnet.ahrq.gov/node/44993/psn-pdf
April 17, 2017 - Surgical patient safety outcomes in critical access
hospitals: how do they compare?
April 17, 2017
Natafgi N, Baloh J, Weigel P, et al. Surgical Patient Safety Outcomes in Critical Access Hospitals: How Do
They Compare? J Rural Health. 2016;33(2):117-126. doi:10.1111/jrh.12176.
https://psnet.ahrq.gov/issue/surgica…
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psnet.ahrq.gov/node/42118/psn-pdf
March 20, 2013 - Simulation exercises as a patient safety strategy: a
systematic review.
March 20, 2013
Schmidt E, Goldhaber-Fiebert SN, Ho LA, et al. Simulation exercises as a patient safety strategy: a
systematic review. Ann Intern Med. 2013;158(5 Pt 2):426-32. doi:10.7326/0003-4819-158-5-201303051-
00010.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/39970/psn-pdf
January 22, 2017 - Hospital board checklist to improve culture and reduce
central line–associated bloodstream infections.
January 22, 2017
Goeschel CA, Holzmueller CG, Pronovost P. Hospital Board Checklist to improve culture and reduce
central line-associated bloodstream infections. Jt Comm J Qual Patient Saf. 2010;36(11):525-8.
htt…
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psnet.ahrq.gov/node/47392/psn-pdf
January 23, 2019 - Effects of a multifaceted medication reconciliation quality
improvement intervention on patient safety: final results
of the MARQUIS study.
January 23, 2019
Schnipper JL, Mixon A, Stein J, et al. Effects of a multifaceted medication reconciliation quality
improvement intervention on patient safety: final results o…
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psnet.ahrq.gov/node/45319/psn-pdf
September 01, 2018 - Special Issue: Progress at the Intersection of Patient
Safety and Medical Liability.
September 1, 2018
Ridgely MS, Greenberg MD, Clancy CM, eds. Health Serv Res. 2016;51(suppl 3):2395-2648.
https://psnet.ahrq.gov/issue/special-issue-progress-intersection-patient-safety-and-medical-liability
Medical liability refor…