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psnet.ahrq.gov/node/37002/psn-pdf
September 14, 2011 - Factors influencing nurses' decisions to raise concerns
about care quality.
September 14, 2011
Attree M. Factors influencing nurses' decisions to raise concerns about care quality. J Nurs Manag.
2007;15(4):392-402.
https://psnet.ahrq.gov/issue/factors-influencing-nurses-decisions-raise-concerns-about-care-quality
…
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psnet.ahrq.gov/node/38021/psn-pdf
August 27, 2008 - A review of the current evidence base for significant
event analysis.
August 27, 2008
Bowie P, Pope L, Lough M. A review of the current evidence base for significant event analysis. J Eval Clin
Pract. 2008;14(4):520-36. doi:10.1111/j.1365-2753.2007.00908.x.
https://psnet.ahrq.gov/issue/review-current-evidence-base…
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psnet.ahrq.gov/node/37736/psn-pdf
April 30, 2008 - Causes of near misses in critical care of neonates and
children.
April 30, 2008
Tourgeman-Bashkin O, Shinar D, Zmora E. Causes of near misses in critical care of neonates and
children. Acta Paediatr. 2008;97(3):299-303. doi:10.1111/j.1651-2227.2007.00616.x.
https://psnet.ahrq.gov/issue/causes-near-misses-critical-…
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psnet.ahrq.gov/node/40781/psn-pdf
September 14, 2011 - Reducing the incidence of retained surgical instrument
fragments.
September 14, 2011
Reece M, Troeleman ND, McGowan JE, et al. Reducing the incidence of retained surgical instrument
fragments. AORN J. 2011;94(3):301-4. doi:10.1016/j.aorn.2011.05.014.
https://psnet.ahrq.gov/issue/reducing-incidence-retained-surgica…
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psnet.ahrq.gov/node/38338/psn-pdf
January 14, 2009 - Implementation of patient safety rounds in a children's
hospital.
January 14, 2009
Yee PL, Edwards ML, Dixon JL, et al. Implementation of patient safety rounds in a children's hospital. Nurs
Adm Q. 2009;33(1):48-53. doi:10.1097/01.NAQ.0000343348.93537.41.
https://psnet.ahrq.gov/issue/implementation-patient-safety-…
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psnet.ahrq.gov/node/37964/psn-pdf
June 29, 2011 - Impact of miscommunication in medical dispute cases in
Japan.
June 29, 2011
Aoki N, Uda K, Ohta S, et al. Impact of miscommunication in medical dispute cases in Japan. Int J Qual
Health Care. 2008;20(5):358-62. doi:10.1093/intqhc/mzn028.
https://psnet.ahrq.gov/issue/impact-miscommunication-medical-dispute-cases-ja…
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - appropriate naloxone use.14,15
Individual providers and healthcare systems need to do a better job of identifying
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psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
February 26, 2025 - The NAPSI team designed a protocol that is nimble and flexible to care as it happens instead of only identifying
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psnet.ahrq.gov/web-mm/pill-organizing-plight
June 19, 2018 - SPOTLIGHT CASE
A Pill Organizing Plight
Citation Text:
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. 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/49768/psn-pdf
September 01, 2016 - A Pill Organizing Plight
September 1, 2016
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/pill-organizing-plight
Case Objectives
Identify patients at high risk for adverse drug events.
List drugs that are considered inappropriate in older patients.
…
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psnet.ahrq.gov/issue/patient-safety-primary-care-has-many-aspects-interview-study-primary-care-doctors-and-nurses
July 23, 2008 - Study
Patient safety in primary care has many aspects: an interview study in primary care doctors and nurses.
Citation Text:
Gaal S, van Laarhoven E, Wolters R, et al. Patient safety in primary care has many aspects: an interview study in primary care doctors and nurses. J Eval Clin Pr…
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psnet.ahrq.gov/issue/toward-translation-systems-thinking-methods-patient-safety-practice-assessing-validity-net
April 21, 2021 - Study
Toward the translation of systems thinking methods in patient safety practice: assessing the validity of Net-HARMS and AcciMap.
Citation Text:
Salmon PM, King B, Hulme A, et al. Toward the translation of systems thinking methods in patient safety practice: assessing the validity of…
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psnet.ahrq.gov/issue/practice-respect-icu
August 09, 2018 - Commentary
Emerging Classic
The practice of respect in the ICU.
Citation Text:
Brown SM, Azoulay E, Benoit D, et al. The Practice of Respect in the ICU. Am J Respir Crit Care Med. 2018;197(11):1389-1395. doi:10.1164/rccm.201708-1676CP.
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psnet.ahrq.gov/issue/safety-medication-use-primary-care
March 04, 2011 - Review
Safety of medication use in primary care.
Citation Text:
Olaniyan JO, Ghaleb M, Dhillon S, et al. Safety of medication use in primary care. Int J Pharm Pract. 2015;23(1):3-20. doi:10.1111/ijpp.12120.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 X…
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psnet.ahrq.gov/issue/patient-and-clinician-experiences-uncertainty-diagnostic-process-current-understanding-and
March 11, 2020 - Commentary
Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions.
Citation Text:
Meyer AND, Giardina TD, Khawaja L, et al. Patient and clinician experiences of uncertainty in the diagnostic process: current understanding a…
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psnet.ahrq.gov/issue/perioperative-patient-safety-recommendations-systematic-review-clinical-practice-guidelines
January 08, 2025 - Study
Perioperative patient safety recommendations: systematic review of clinical practice guidelines.
Citation Text:
Martínez-Nicolas I, Arnal-Velasco D, Romero-García E, et al. Perioperative patient safety recommendations: systematic review of clinical practice guidelines. BJS Open. 20…
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psnet.ahrq.gov/issue/evaluation-measure-dx-resource-accelerate-diagnostic-safety-learning-and-improvement
February 07, 2024 - Study
Evaluation of Measure Dx, a resource to accelerate diagnostic safety learning and improvement.
Citation Text:
Bradford A, Tran A, Ali KJ, et al. Evaluation of Measure Dx, a resource to accelerate diagnostic safety learning and improvement. J Gen Intern Med. . 2024;Epub Oct 22. doi:…
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psnet.ahrq.gov/issue/situation-background-assessment-recommendation-sbar-communication-tool-handoff-health-care
March 03, 2021 - Review
Emerging Classic
Situation, background, assessment, recommendation (SBAR) communication tool for handoff in health care- a narrative review.
Citation Text:
Shahid S, Thomas S. Situation, background, assessment, recommendation (SBAR) communication tool for…
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psnet.ahrq.gov/issue/workarounds-intended-use-health-information-technology-narrative-review-human-factors
July 24, 2013 - Review
Emerging Classic
Workarounds to intended use of health information technology: a narrative review of the human factors engineering literature.
Citation Text:
Patterson ES. Workarounds to Intended Use of Health Information Technology: A Narrative Review of…
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psnet.ahrq.gov/issue/association-simulation-training-rates-medical-malpractice-claims-among-obstetrician
December 02, 2020 - Study
Association of simulation training with rates of medical malpractice claims among obstetrician-gynecologists.
Citation Text:
Schaffer AC, Babayan A, Einbinder JS, et al. Association of simulation training with rates of medical malpractice claims among obstetrician-gynecologists. Ob…