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psnet.ahrq.gov/node/40412/psn-pdf
March 23, 2012 - Veterans Affairs initiative to prevent methicillin-resistant
Staphylococcus aureus infections.
March 23, 2012
Jain R, Kralovic SM, Evans ME, et al. Veterans Affairs initiative to prevent methicillin-resistant
Staphylococcus aureus infections. N Engl J Med. 2011;364(15):1419-30. doi:10.1056/NEJMoa1007474.
https://p…
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psnet.ahrq.gov/node/46340/psn-pdf
September 27, 2017 - A systematic review of the effectiveness of interruptive
medication prescribing alerts in hospital CPOE systems
to change prescriber behavior and improve patient safety.
September 27, 2017
Page N, Baysari MT, Westbrook JI. A systematic review of the effectiveness of interruptive medication
prescribing alerts in ho…
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psnet.ahrq.gov/node/44471/psn-pdf
September 27, 2016 - Two sides of the safety coin?: how patient engagement
and safety climate jointly affect error occurrence in
hospital units.
September 27, 2016
Schiffinger M, Latzke M, Steyrer J. Two sides of the safety coin?: How patient engagement and safety
climate jointly affect error occurrence in hospital units. Health Care …
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psnet.ahrq.gov/node/45511/psn-pdf
July 21, 2017 - Can patient involvement improve patient safety? A cluster
randomised control trial of the Patient Reporting and
Action for a Safe Environment (PRASE) intervention.
July 21, 2017
Lawton R, O'Hara JK, Sheard L, et al. Can patient involvement improve patient safety? A cluster
randomised control trial of the Patient R…
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psnet.ahrq.gov/node/46295/psn-pdf
September 06, 2017 - Pain assessment and management standards for
hospitals.
September 6, 2017
R3 Report. August 29, 2017;11:1-7.
https://psnet.ahrq.gov/issue/pain-assessment-and-management-standards-hospitals
Strategies to manage pain safely have been reexamined in light of the opioid epidemic. This report
highlights Joint Commissio…
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psnet.ahrq.gov/node/44457/psn-pdf
September 29, 2017 - Hospitals slow to adopt patient apology policies.
September 29, 2017
Rice S. Hospitals slow to adopt patient apology policies. Modern healthcare. 2015;45(33):16, 29-30.
https://psnet.ahrq.gov/issue/hospitals-slow-adopt-patient-apology-policies
Communication-and-resolution approaches to medical errors have garnered …
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psnet.ahrq.gov/node/43657/psn-pdf
November 26, 2014 - Strategies for Ensuring the Safe Use of Insulin Pens in the
Hospital.
November 26, 2014
American Society of Health-System Pharmacists
https://psnet.ahrq.gov/issue/strategies-ensuring-safe-use-insulin-pens-hospital
Insulin is classified as a high-alert medication due to the potential to cause serious patient harm w…
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psnet.ahrq.gov/node/45223/psn-pdf
September 27, 2017 - Hospital safety climate and safety behavior: a social
exchange perspective.
September 27, 2017
Ancarani A, Di Mauro C, Giammanco MD. Hospital safety climate and safety behavior: A social exchange
perspective. Health Care Manage Rev. 2017;42(4):341-351. doi:10.1097/HMR.0000000000000118.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/853076/psn-pdf
August 30, 2023 - Hospital bosses ignored months of doctors' warnings
about Lucy Letby.
August 30, 2023
Moritz J, Coffey J, Buchanan M. BBC News. August 19, 2023.
https://psnet.ahrq.gov/issue/hospital-bosses-ignored-months-doctors-warnings-about-lucy-letby
Whistleblowers can identify the presence of systemic failures, but the organ…
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psnet.ahrq.gov/node/46167/psn-pdf
June 07, 2017 - Identifying patients with sepsis on the hospital wards.
June 7, 2017
Bhattacharjee P, Edelson DP, Churpek MM. Identifying Patients With Sepsis on the Hospital Wards. Chest.
2016;151(4). doi:10.1016/j.chest.2016.06.020.
https://psnet.ahrq.gov/issue/identifying-patients-sepsis-hospital-wards
Undiagnosed sepsis can l…
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psnet.ahrq.gov/node/39498/psn-pdf
February 10, 2015 - The effect of health information technology on quality in
U.S. hospitals.
February 10, 2015
McCullough JS, Casey M, Moscovice I, et al. The effect of health information technology on quality in U.S.
hospitals. Health Aff (Millwood). 2010;29(4):647-654. doi:10.1377/hlthaff.2010.0155.
https://psnet.ahrq.gov/issue/ef…
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psnet.ahrq.gov/node/44531/psn-pdf
September 30, 2015 - Never Events for Hospital Care in Canada: Safer Care for
Patients.
September 30, 2015
Toronto, ON: Health Quality Ontario and the Canadian Patient Safety Institute; September 2015. ISBN:
9781460666180.
https://psnet.ahrq.gov/issue/never-events-hospital-care-canada-safer-care-patients
The never events list was dev…
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psnet.ahrq.gov/node/39647/psn-pdf
November 02, 2010 - Validation of hospital administrative dataset for adverse
event screening.
November 2, 2010
Verelst S, Jacques J, Van den Heede K, et al. Validation of Hospital Administrative Dataset for adverse
event screening. Qual Saf Health Care. 2010;19(5):e25. doi:10.1136/qshc.2009.034306.
https://psnet.ahrq.gov/issue/valid…
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psnet.ahrq.gov/node/40329/psn-pdf
August 25, 2011 - Using prospective clinical surveillance to identify adverse
events in hospital.
August 25, 2011
Forster AJ, Worthington JR, Hawken S, et al. Using prospective clinical surveillance to identify adverse
events in hospital. BMJ Qual Saf. 2011;20(9):756-63. doi:10.1136/bmjqs.2010.048694.
https://psnet.ahrq.gov/issue/u…
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psnet.ahrq.gov/node/867395/psn-pdf
December 18, 2024 - AHRQ National Healthcare Safety Dashboard.
December 18, 2024
AHRQ National Healthcare Safety Dashboard. National Action Alliance for Patient and Workforce Safety.
https://psnet.ahrq.gov/issue/ahrq-national-healthcare-safety-dashboard
The AHRQ National Healthcare Safety Dashboard is one approach to tracking progress…
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psnet.ahrq.gov/node/39059/psn-pdf
October 28, 2009 - Communication and information deficits in patients
discharged to rehabilitation facilities: an evaluation of five
acute care hospitals.
October 28, 2009
Gandara E, Moniz T, Ungar J, et al. Communication and information deficits in patients discharged to
rehabilitation facilities: An evaluation of five acute care h…
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psnet.ahrq.gov/node/39090/psn-pdf
November 11, 2009 - Nurse reports of adverse events during sedation
procedures at a pediatric hospital.
November 11, 2009
Lightdale JR, Mahoney LB, Fredette ME, et al. Nurse reports of adverse events during sedation procedures
at a pediatric hospital. J Perianesth Nurs. 2009;24(5):300-6. doi:10.1016/j.jopan.2009.07.004.
https://psnet…
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psnet.ahrq.gov/node/33926/psn-pdf
March 07, 2005 - The problems of detecting medication errors in hospitals.
March 7, 2005
Barker KN, McConnell WE. The Problems of Detecting Medication Errors in Hospitals. Am J Health Syst
Pharm. 1962;19(8):360-369. doi:10.1093/ajhp/19.8.360.
https://psnet.ahrq.gov/issue/problems-detecting-medication-errors-hospitals
Perhaps the f…
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psnet.ahrq.gov/node/42355/psn-pdf
February 11, 2015 - Advancing Successful Care Transitions to Improve
Outcomes.
February 11, 2015
Society of Hospital Medicine
https://psnet.ahrq.gov/issue/project-boost-mentored-implementation-program
This Web site provides resources associated with the Better Outcomes for Older adults through Safe
Transitions project, called Projec…
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psnet.ahrq.gov/node/50580/psn-pdf
October 23, 2019 - Suspicious insulin injections, nearly a dozen deaths:
inside an unfolding investigation at a VA hospital in West
Virginia.
October 23, 2019
Rein L. Washington Post. October 5, 2019.
https://psnet.ahrq.gov/issue/suspicious-insulin-injections-nearly-dozen-deaths-inside-unfolding-
investigation-va-hospital
The Vete…