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psnet.ahrq.gov/node/45457/psn-pdf
September 01, 2016 - Patient safety implications of electronic alerts and alarms
of maternal–fetal status during labor.
September 1, 2016
Simpson KR, Lyndon A, Davidson LA. Patient Safety Implications of Electronic Alerts and Alarms of
Maternal - Fetal Status During Labor. Nurs Womens Health. 2016;20(4):358-66.
doi:10.1016/j.nwh.2016.…
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psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
January 24, 2018 - Primary Workaround, Secondary Complication
Citation Text:
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - Managing Ascites: Hazards of Fluid Removal
Citation Text:
Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/missing-point-eye-injury
March 01, 2005 - Missing the Point—Eye Injury
Citation Text:
Sharma R, Brunette DD. Missing the Point—Eye Injury. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
February 01, 2014 - Wrong-Time Error With High-Alert Medication
Citation Text:
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/44011/psn-pdf
May 06, 2015 - Resident physicians' clinical training and error rate: the
roles of autonomy, consultation, and familiarity with the
literature.
May 6, 2015
Naveh E, Katz-Navon T, Stern Z. Resident physicians' clinical training and error rate: the roles of
autonomy, consultation, and familiarity with the literature. Adv Health Sc…
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psnet.ahrq.gov/node/36837/psn-pdf
December 03, 2018 - Hospitals as cultures of entrapment: a re-analysis of the
Bristol Royal Infirmary.
December 3, 2018
Weick KE, Sutcliffe KM. Hospitals as Cultures of Entrapment: A Re-Analysis of the Bristol Royal Infirmary.
Calif Manage Rev. 2012;45(2):73-84. doi:10.2307/41166166.
https://psnet.ahrq.gov/issue/hospitals-cultures-en…
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psnet.ahrq.gov/node/48071/psn-pdf
June 12, 2019 - Doctors were alarmed: would I have my children have
surgery here?
June 12, 2019
Gabler E. New York Times. May 31, 2019.
https://psnet.ahrq.gov/issue/doctors-were-alarmed-would-i-have-my-children-have-surgery-here
Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly
p…
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psnet.ahrq.gov/node/74182/psn-pdf
December 15, 2021 - Honesty and transparency, indispensable to the clinical
mission--Parts I-III.
December 15, 2021
Brenner MJ, Boothman RC, Rushton CH, et al. Honesty and Transparency, Indispensable to the Clinical
Mission—Parts I - III. Otolaryngol Clin North Am. 2021;55(1):43-103. doi:10.1016/j.otc.2021.07.016.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/866447/psn-pdf
August 07, 2024 - Older adults are often misdiagnosed. Specialized ERs and
trained clinicians can help.
August 7, 2024
Milne-Tyte A. Older adults are often misdiagnosed. Specialized ERs and trained clinicians can help. Health
Shots. National Public Radio. July 30, 2024;
https://psnet.ahrq.gov/issue/older-adults-are-often-misdiagnos…
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psnet.ahrq.gov/node/46601/psn-pdf
January 25, 2018 - Night-time communication at Stanford University
Hospital: perceptions, reality and solutions.
January 25, 2018
Sun AJ, Wang L, Go M, et al. Night-time communication at Stanford University Hospital: perceptions, reality
and solutions. BMJ Qual Saf. 2018;27(2):156-162. doi:10.1136/bmjqs-2017-006727.
https://psnet.ah…
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psnet.ahrq.gov/node/46654/psn-pdf
December 13, 2017 - Organisational paradoxes in speaking up for safety:
implications for the interprofessional field.
December 13, 2017
Rowland P. Organisational paradoxes in speaking up for safety: Implications for the interprofessional field.
J Interprof Care. 2017;31(5):553-556. doi:10.1080/13561820.2017.1321305.
https://psnet.ahr…
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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/73135/psn-pdf
April 14, 2021 - Debrief it all: a tool for inclusion of Safety-II.
April 14, 2021
Bentley SK, McNamara S, Meguerdichian MJ, et al. Debrief it all: a tool for inclusion of Safety-II. Adv Simul
(Lond). 2021;6(1):9. doi:10.1186/s41077-021-00163-3.
https://psnet.ahrq.gov/issue/debrief-it-all-tool-inclusion-safety-ii
Debriefing is a c…
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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/46335/psn-pdf
December 19, 2017 - Prescription opioid analgesics commonly unused after
surgery: a systematic review.
December 19, 2017
Bicket MC, Long JJ, Pronovost PJ, et al. Prescription Opioid Analgesics Commonly Unused After Surgery.
JAMA Surg. 2017;152(11):1066-1071. doi:10.1001/jamasurg.2017.0831.
https://psnet.ahrq.gov/issue/prescription-op…
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psnet.ahrq.gov/node/843327/psn-pdf
February 01, 2023 - Speaking up during the COVID-19 pandemic: nurses'
experiences of organizational disregard and silence.
February 1, 2023
Abrams R, Conolly A, Rowland E, et al. Speaking up during the COVID?19 pandemic: nurses' experiences
of organizational disregard and silence. J Adv Nurs. 2023;79(6):2189-2199. doi:10.1111/jan.1552…
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psnet.ahrq.gov/node/73217/psn-pdf
May 05, 2021 - Assessing patients 2019 experiences with medical injury
reconciliation processes: item generation for a novel
survey questionnaire.
May 5, 2021
Schulz-Moore JS, Bismark M, Jenkinson C, et al. Assessing patients 2019 experiences with medical injury
reconciliation processes: item generation for a novel survey questi…
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psnet.ahrq.gov/node/837594/psn-pdf
June 29, 2022 - Machine learning models outperform manual result
review for the identification of wrong blood in tube errors
in complete blood count results.
June 29, 2022
Farrell C?JL, Giannoutsos J. Machine learning models outperform manual result review for the
identification of wrong blood in tube errors in complete blood cou…
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psnet.ahrq.gov/node/50889/psn-pdf
February 12, 2020 - Unscheduled radiologic examination orders in the
electronic health record: a novel resource for targeting
ambulatory diagnostic errors in radiology.
February 12, 2020
Lacson R, Healey MJ, Cochon LR, et al. Unscheduled Radiologic Examination Orders in the Electronic
Health Record: A Novel Resource for Targeting Amb…