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psnet.ahrq.gov/node/72857/psn-pdf
March 17, 2021 - Results and lessons from a hospital-wide initiative
incentivised by delivery system reform to improve
infection prevention and sepsis care.
March 17, 2021
Sreeramoju P, Voy-Hatter K, White C, et al. Results and lessons from a hospital-wide initiative incentivised
by delivery system reform to improve infection prev…
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psnet.ahrq.gov/node/47505/psn-pdf
March 19, 2019 - Measuring the teamwork performance of teams in crisis
situations: a systematic review of assessment tools and
their measurement properties.
March 19, 2019
Boet S, Etherington N, Larrigan S, et al. Measuring the teamwork performance of teams in crisis situations:
a systematic review of assessment tools and their me…
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psnet.ahrq.gov/node/46201/psn-pdf
September 27, 2017 - Risk factors for patient-reported errors during cancer
follow-up: results from a national survey in Denmark.
September 27, 2017
Christiansen AH, Lipczak H, Knudsen JL, et al. Risk factors for patient-reported errors during cancer follow-
up: Results from a national survey in Denmark. Cancer Epidemiol. 2017;49:38-45…
-
psnet.ahrq.gov/node/39917/psn-pdf
October 13, 2010 - Prevalence of adverse events in pediatric intensive care
units in the United States.
October 13, 2010
Agarwal S, Classen D, Larsen G, et al. Prevalence of adverse events in pediatric intensive care units in the
United States. Pediatr Crit Care Med. 2010;11(5):568-578. doi:10.1097/PCC.0b013e3181d8e405.
https://psne…
-
psnet.ahrq.gov/node/43227/psn-pdf
June 04, 2014 - Detecting adverse events in surgery: comparing events
detected by the Veterans Health Administration Surgical
Quality Improvement Program and the Patient Safety
Indicators.
June 4, 2014
Mull HJ, Borzecki A, Loveland S, et al. Detecting adverse events in surgery: comparing events detected by
the Veterans Health Ad…
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psnet.ahrq.gov/node/36345/psn-pdf
November 15, 2011 - Risk reduction for adverse drug events through
sequential implementation of patient safety initiatives in a
children's hospital.
November 15, 2011
Leonard MS, Cimino M, Shaha S, et al. Risk reduction for adverse drug events through sequential
implementation of patient safety initiatives in a children's hospital. P…
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psnet.ahrq.gov/node/866745/psn-pdf
September 18, 2024 - State of the Science and Future Directions to Improve
Diagnostic Safety in Older Adults.
September 18, 2024
Tran AK, Syed Q, Bierman AS, et al. State Of The Science And Future Directions To Improve Diagnostic
Safety In Older Adults. Rockville, MD: Agency for Healthcare Research and Quality; September 2024.
AHRQ Pu…
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psnet.ahrq.gov/node/45967/psn-pdf
July 05, 2017 - Root-cause analysis: swatting at mosquitoes versus
draining the swamp.
July 5, 2017
Trbovich PL, Shojania KG. Root-cause analysis: swatting at mosquitoes versus draining the swamp. BMJ
Qual Saf. 2017;26(5):350-353. doi:10.1136/bmjqs-2016-006229.
https://psnet.ahrq.gov/issue/root-cause-analysis-swatting-mosquitoes-…
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psnet.ahrq.gov/node/46819/psn-pdf
January 27, 2019 - Implementing electronic health record default settings to
reduce opioid overprescribing: a pilot study.
January 27, 2019
Zivin K, White JO, Chao S, et al. Implementing Electronic Health Record Default Settings to Reduce Opioid
Overprescribing: A Pilot Study. Pain Med. 2019;20(1):103-112. doi:10.1093/pm/pnx304.
htt…
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psnet.ahrq.gov/node/44768/psn-pdf
February 03, 2016 - Recommendations and low-technology safety solutions
following neuromuscular blocking agent incidents.
February 3, 2016
Graudins L, Downey G, Bui T, et al. Recommendations and Low-Technology Safety Solutions Following
Neuromuscular Blocking Agent Incidents. Jt Comm J Qual Patient Saf. 2016;42(2):86-91.
https://psne…
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psnet.ahrq.gov/node/34818/psn-pdf
April 22, 2011 - The Canadian Adverse Events Study: the incidence of
adverse events among hospital patients in Canada.
April 22, 2011
Baker R, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events
among hospital patients in Canada. CMAJ. 2004;170(11):1678-86.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/866161/psn-pdf
June 19, 2024 - Patient Safety Indicators at an academic veterans affairs
hospital: addressing dual goals of clinical care and
validity.
June 19, 2024
Allaudeen N, Schalch E, Neff M, et al. Patient Safety Indicators at an Academic Veterans Affairs Hospital:
Addressing Dual Goals of Clinical Care and Validity. Jt Comm J Qual Patie…
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psnet.ahrq.gov/node/856586/psn-pdf
November 29, 2023 - The complexities of communication at hospital discharge
of older patients: a qualitative study of healthcare
professionals' views.
November 29, 2023
Cam H, Wennlöf B, Gillespie U, et al. The complexities of communication at hospital discharge of older
patients: a qualitative study of healthcare professionals’ view…
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psnet.ahrq.gov/node/844764/psn-pdf
September 11, 2019 - IV Push Gap Analysis Tool (GAT) helps uncover national
priorities for safe injection practices.
September 11, 2019
ISMP Medication Safety Alert! Acute Care Edition. August 29, 2019;24.
https://psnet.ahrq.gov/issue/iv-push-gap-analysis-tool-gat-helps-uncover-national-priorities-safe-injection-
practices
Mistakes i…
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psnet.ahrq.gov/node/40841/psn-pdf
October 16, 2012 - How dangerous is a day in hospital?: A model of adverse
events and length of stay for medical inpatients.
October 16, 2012
Hauck K, Zhao X. How dangerous is a day in hospital? A model of adverse events and length of stay for
medical inpatients. Med Care. 2011;49(12):1068-75. doi:10.1097/MLR.0b013e31822efb09.
https…
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psnet.ahrq.gov/node/47127/psn-pdf
June 05, 2018 - Incorporating medication indications into the prescribing
process.
June 5, 2018
Kron K, Myers S, Volk LA, et al. Incorporating medication indications into the prescribing process. Am J
Health-syst Pharm. 2018;75(11):774-783. doi:10.2146/ajhp170346.
https://psnet.ahrq.gov/issue/incorporating-medication-indications-…
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psnet.ahrq.gov/node/849132/psn-pdf
May 17, 2023 - Qualitative perspectives of emergency nurses on
electronic health record behavioral flags to promote
workplace safety.
May 17, 2023
Seeburger EF, Gonzales R, South EC, et al. Qualitative perspectives of emergency nurses on electronic
health record behavioral flags to promote workplace safety. JAMA Netw Open. 2023;…
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psnet.ahrq.gov/node/73070/psn-pdf
March 24, 2021 - Incidence, duration and risk factors associated with
delayed and missed diagnostic opportunities related to
tuberculosis: a population-based longitudinal study.
March 24, 2021
Miller AC, Arakkal AT, Koeneman S, et al. Incidence, duration and risk factors associated with delayed and
missed diagnostic opportunities …
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psnet.ahrq.gov/node/47606/psn-pdf
January 30, 2019 - Importance of safety climate, teamwork climate and
demographics: understanding nurses, allied health
professionals and clerical staff perceptions of patient
safety.
January 30, 2019
Zaheer S, Ginsburg LR, Wong HJ, et al. Importance of safety climate, teamwork climate and
demographics: understanding nurses, allied…
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psnet.ahrq.gov/node/60877/psn-pdf
September 02, 2020 - When bad things happen: training medical students to
anticipate the aftermath of medical errors.
September 2, 2020
Musunur S, Waineo E, Walton E, et al. When bad things happen: training medical students to anticipate the
aftermath of medical errors. Acad Psychiatry. 2020;44(5):586-591. doi:10.1007/s40596-020-01278-…