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psnet.ahrq.gov/node/50457/psn-pdf
October 09, 2019 - Combined SNA and LDA methods to understand adverse
medical events
October 9, 2019
Zhu L, Reychav I, McHaney R, et al. Combined SNA and LDA methods to understand adverse medical
events. Int J Risk Saf Med. 2019;30(3):129-153. doi:10.3233/JRS-180052.
https://psnet.ahrq.gov/issue/combined-sna-and-lda-methods-understa…
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psnet.ahrq.gov/node/44363/psn-pdf
May 05, 2018 - Selection of incorrect medication pump leads to
chemotherapy overdose.
May 5, 2018
ISMP Canada. August 26, 2015;15:1-4.
https://psnet.ahrq.gov/issue/selection-incorrect-medication-pump-leads-chemotherapy-overdose
Checklists are cognitive aids that help clinicians remember important steps to ensure safe practice. I…
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psnet.ahrq.gov/node/45176/psn-pdf
July 20, 2016 - Sustaining Improvement.
July 20, 2016
Scoville R, Little K, Rakover J, et al. Cambridge, Massachusetts: Institute for Healthcare Improvement;
2016.
https://psnet.ahrq.gov/issue/sustaining-improvement
Numerous activities and programs have been launched to improve patient safety, but sustaining
improvements can be …
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psnet.ahrq.gov/node/45777/psn-pdf
January 11, 2017 - Disclosure of adverse events in pediatrics.
January 11, 2017
McDonnell WM; Altman RL; Bondi SA et al for the Committee on Medical Liability and Risk Management;
Council on Quality Improvement and Patient Safety. Pediatrics. 2016;138(6);e20163215.
https://psnet.ahrq.gov/issue/disclosure-adverse-events-pediatrics
Op…
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psnet.ahrq.gov/node/45450/psn-pdf
February 13, 2018 - Avoiding Unconscious Bias: a Guide for Surgeons.
February 13, 2018
London, UK: Royal College of Surgeons of England; 2016.
https://psnet.ahrq.gov/issue/avoiding-unconscious-bias-guide-surgeons
Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides
information for sur…
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psnet.ahrq.gov/node/35304/psn-pdf
July 14, 2009 - Medication error in the care of HIV/AIDS patients:
electronic surveillance, confirmation, and adverse events.
July 14, 2009
DeLorenze GN, Follansbee SF, Nguyen DP, et al. Medication error in the care of HIV/AIDS patients:
electronic surveillance, confirmation, and adverse events. Med Care. 2005;43(9 Suppl):III63-II…
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psnet.ahrq.gov/node/41598/psn-pdf
August 15, 2012 - Obstetrician/gynecologist hospitalists: can we improve
safety and outcomes for patients and hospitals and
improve lifestyle for physicians?
August 15, 2012
Olson R, Garite TJ, Fishman A, et al. Obstetrician/gynecologist hospitalists: can we improve safety and
outcomes for patients and hospitals and improve lifesty…
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psnet.ahrq.gov/node/838139/psn-pdf
September 21, 2022 - Error traps in acute pain management in children.
September 21, 2022
Vecchione TM, Agarwal R, Monitto CL. Error traps in acute pain management in children. Paediatr
Anaesth. 2022;32(9):982-992. doi:10.1111/pan.14514.
https://psnet.ahrq.gov/issue/error-traps-acute-pain-management-children
Appropriate pediatric pain…
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psnet.ahrq.gov/node/866359/psn-pdf
June 01, 2022 - Diagnostic Safety Toolkit.
June 1, 2022
Diagnostic Safety Toolkit.
https://psnet.ahrq.gov/issue/diagnostic-safety-toolkit-0
Effective communication is critical as patients shift from one level of care to another as their diagnosis
evolves. This toolkit is designed to help academic medical centers initiate conversa…
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psnet.ahrq.gov/node/44135/psn-pdf
November 06, 2015 - Freedom to Speak Up: A Review of Whistleblowing in the
NHS.
November 6, 2015
Francis R. London, UK: Department of Health; February 2015.
https://psnet.ahrq.gov/issue/freedom-speak-review-whistleblowing-nhs
Staff willingness to raise awareness of problems that could affect patient care is an important indicator of
…
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psnet.ahrq.gov/node/44565/psn-pdf
October 14, 2015 - How to use online clinician rating systems.
October 14, 2015
Razmaria AA, Livingston EH. JAMA PATIENT PAGE. How to Use Online Clinician Rating Systems. JAMA.
2015;314(13):1418. doi:10.1001/jama.2015.11957.
https://psnet.ahrq.gov/issue/how-use-online-clinician-rating-systems
Clinician rating sites may not always pr…
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psnet.ahrq.gov/node/44966/psn-pdf
March 16, 2016 - Confidential Physician Feedback Reports: Designing for
Optimal Impact on Performance.
March 16, 2016
McNamara P, Shaller D, De La Mare J, Ivers N. Rockville, MD: Agency for Healthcare Research and
Quality; March 2016. AHRQ Publication No. 16-0017-EF.
https://psnet.ahrq.gov/issue/confidential-physician-feedback-rep…
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psnet.ahrq.gov/node/41356/psn-pdf
May 29, 2012 - Safety in the home healthcare sector: development of a
new household safety checklist.
May 29, 2012
Gershon RRM, Dailey M, Magda LA, et al. Safety in the home healthcare sector: development of a new
household safety checklist. J Patient Saf. 2012;8(2):51-9. doi:10.1097/PTS.0b013e31824a4ad6.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/44567/psn-pdf
October 14, 2015 - The misery of a doctor's first days.
October 14, 2015
Hester JL. The Atlantic. October 1, 2015.
https://psnet.ahrq.gov/issue/misery-doctors-first-days
Although there is no consensus regarding whether the "July effect" actually exists, it is not hard to imagine
the difficulties associated with the first days of pra…
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psnet.ahrq.gov/node/44016/psn-pdf
November 21, 2016 - Partnering to Improve Quality and Safety: A Framework
for Working With Patient and Family Advisors.
November 21, 2016
Chicago, IL: Health Research & Educational Trust; 2015.
https://psnet.ahrq.gov/issue/partnering-improve-quality-and-safety-framework-working-patient-and-family-
advisors
Patient and family advisor…
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psnet.ahrq.gov/node/44091/psn-pdf
January 04, 2019 - Isolation precautions for visitors.
January 4, 2019
Munoz-Price LS, Banach DB, Bearman G, et al. Isolation Precautions for Visitors. Infect Control Hosp
Epidemiol. 2015;36(7):747-758. doi:10.1017/ice.2015.67.
https://psnet.ahrq.gov/issue/isolation-precautions-visitors
This expert guidance provides recommendations …
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psnet.ahrq.gov/node/45606/psn-pdf
October 27, 2016 - Unprofessional workplace conduct...defining and
defusing it.
October 27, 2016
MacLean L, Coombs C, Breda K. Unprofessional workplace conduct..defining and defusing it. Nurs
Manage. 2016;47(9):30-34. doi:10.1097/01.NUMA.0000491126.68354.be.
https://psnet.ahrq.gov/issue/unprofessional-workplace-conductdefining-and-d…
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psnet.ahrq.gov/node/43936/psn-pdf
December 04, 2015 - Exploring the Potential Use of Safety Cases in Health
Care.
December 4, 2015
Safety Cases Working Group. London, UK: Health Foundation; 2015.
https://psnet.ahrq.gov/issue/exploring-potential-use-safety-cases-health-care
This report describes a consensus-building initiative in the United Kingdom seeking to determin…
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psnet.ahrq.gov/node/41222/psn-pdf
May 01, 2016 - Reducing Unnecessary Hospital Readmissions: The Role
of the Patient Safety Organization (PSO).
May 1, 2016
Agency for Healthcare Quality and Research.
https://psnet.ahrq.gov/issue/reducing-unnecessary-hospital-readmissions-role-patient-safety-organization-
pso
Patient safety organizations (PSO) present a unique o…
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psnet.ahrq.gov/node/43948/psn-pdf
May 20, 2015 - Human factors engineering: its place and potential in OR
safety.
May 20, 2015
Criscitelli T. Human factors engineering: its place and potential in OR safety. AORN J. 2015;101(5):571-3.
doi:10.1016/j.aorn.2015.02.013.
https://psnet.ahrq.gov/issue/human-factors-engineering-its-place-and-potential-or-safety
Human fa…