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psnet.ahrq.gov/node/35059/psn-pdf
June 22, 2009 - Adverse events associated with sedatives, analgesics,
and other drugs that provide patient comfort in the
intensive care unit.
June 22, 2009
Riker RR, Fraser GL. Adverse events associated with sedatives, analgesics, and other drugs that provide
patient comfort in the intensive care unit. Pharmacotherapy. 2005;25…
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psnet.ahrq.gov/node/42487/psn-pdf
September 27, 2017 - 'Safe enough in here?': Patients' expectations and
experiences of feeling safe in an acute psychiatric
inpatient ward.
September 27, 2017
Stenhouse RC. 'Safe enough in here?': patients' expectations and experiences of feeling safe in an acute
psychiatric inpatient ward. J Clin Nurs. 2013;22(21-22):3109-19. doi:10.…
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psnet.ahrq.gov/node/45320/psn-pdf
January 01, 2017 - The problem with the '5 whys.'
September 14, 2016
Card AJ. The problem with '5 whys'. BMJ Qual Saf. 2017;26(8):671-677. doi:10.1136/bmjqs-2016-005849.
https://psnet.ahrq.gov/issue/problem-5-whys
Investigation of incidents in complex systems can be hindered by time limitations, lack of follow-up, and
incomplete res…
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psnet.ahrq.gov/node/38926/psn-pdf
November 13, 2009 - "Canary measures" among the AHRQ Patient Safety
Indicators.
November 13, 2009
Yu H, Greenberg MD, Haviland AM, et al. "Canary measures" among the AHRQ patient safety indicators.
Am J Med Qual. 2009;24(6):465-73. doi:10.1177/1062860609341585.
https://psnet.ahrq.gov/issue/canary-measures-among-ahrq-patient-safety-in…
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psnet.ahrq.gov/node/38702/psn-pdf
June 10, 2009 - An exploratory study measuring verbal order content and
context.
June 10, 2009
Wakefield DS, Brokel J, Ward MM, et al. An exploratory study measuring verbal order content and context.
Qual Saf Health Care. 2009;18(3):169-73. doi:10.1136/qshc.2008.029827.
https://psnet.ahrq.gov/issue/exploratory-study-measuring-ver…
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psnet.ahrq.gov/node/40447/psn-pdf
March 04, 2015 - Analysis and prioritization of near-miss adverse events in
a radiology department.
March 4, 2015
Thornton RH, Miransky J, Killen A, et al. Analysis and prioritization of near-miss adverse events in a
radiology department. AJR Am J Roentgenol. 2011;196(5):1120-4. doi:10.2214/AJR.10.5373.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/60741/psn-pdf
July 29, 2020 - As college students return, a crisis in campus care
awaits.
July 29, 2020
Abelson J, Tran AB, Kornfield M, et al. As college students return, a crisis in campus care awaits. The
Seattle Times. 2020;July 13.
https://psnet.ahrq.gov/issue/college-students-return-crisis-campus-care-awaits
The COVID-19 pandemic has im…
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psnet.ahrq.gov/node/47791/psn-pdf
March 20, 2019 - Essential activities for electronic health record safety: a
qualitative study.
March 20, 2019
Ash JS, Singh H, Wright A, et al. Essential activities for electronic health record safety: A qualitative study.
Health Informatics J. 2019:1460458219833109. doi:10.1177/1460458219833109.
https://psnet.ahrq.gov/issue/esse…
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psnet.ahrq.gov/node/72685/psn-pdf
January 27, 2021 - Human Factors and Ergonomics in Healthcare.
January 27, 2021
Carayon P, Hignett S, Albolino S eds. Int J Qual Health Care. 2021;33(Supp1):1-71.
https://psnet.ahrq.gov/issue/human-factors-and-ergonomics-healthcare
Human factors approaches have been identified as one of the primary vehicles to create las…
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psnet.ahrq.gov/node/73327/psn-pdf
January 25, 2022 - ISMP Medication Safety Self Assessment® for
Perioperative Settings.
January 25, 2022
Institute for Safe Medication Practices
https://psnet.ahrq.gov/issue/ismp-medication-safety-self-assessmentr-perioperative-settings
The perioperative setting is a high-risk area for medication errors, should they occur. This asses…
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psnet.ahrq.gov/node/39440/psn-pdf
September 19, 2016 - Toward understanding errors in inpatient psychiatry: a
qualitative inquiry.
September 19, 2016
Cullen SW, Nath SB, Marcus SC. Toward understanding errors in inpatient psychiatry: a qualitative inquiry.
Psychiatr Q. 2010;81(3):197-205. doi:10.1007/s11126-010-9129-z.
https://psnet.ahrq.gov/issue/toward-understanding…
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psnet.ahrq.gov/node/36166/psn-pdf
June 14, 2011 - Identification of root causes for emergency diagnostic
imaging delays at three Canadian hospitals.
June 14, 2011
Worster A, Fernandes CMB, Malcolmson C, et al. Identification of root causes for emergency diagnostic
imaging delays at three Canadian hospitals. J Emerg Nurs. 2006;32(4):276-280.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/42631/psn-pdf
November 08, 2013 - "That was a close call": endorsing a broad definition of
near misses in health care.
November 8, 2013
Marks CM, Kasda E, Paine LA, et al. "That was a close call": endorsing a broad definition of near misses in
health care. Jt Comm J Qual Patient Saf. 2013;39(10):475-479.
https://psnet.ahrq.gov/issue/was-close-call…
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psnet.ahrq.gov/node/36905/psn-pdf
September 01, 2011 - Engineering a safe landing: engaging medical
practitioners in a systems approach to patient safety.
September 1, 2011
Brand C, Ibrahim JE, Bain C, et al. Engineering a safe landing: engaging medical practitioners in a systems
approach to patient safety. Intern Med J. 2007;37(5):295-302.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/36841/psn-pdf
December 31, 2014 - Using medical malpractice closed claims data to reduce
surgical risk and improve patient safety.
December 31, 2014
Manuel BM, Greenwald LM. Using medical malpractice closed claims data to reduce surgical risk and
improve patient safety. Bull Am Coll Surg. 2007;92(3):27-30.
https://psnet.ahrq.gov/issue/using-medica…
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psnet.ahrq.gov/node/42780/psn-pdf
June 17, 2014 - Intrathecal chemotherapy: potential for medication error.
June 17, 2014
Gilbar PJ. Intrathecal chemotherapy: potential for medication error. Cancer Nurs. 2014;37(4):299-309.
doi:10.1097/NCC.0000000000000108.
https://psnet.ahrq.gov/issue/intrathecal-chemotherapy-potential-medication-error
This systematic review of …
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psnet.ahrq.gov/node/42452/psn-pdf
July 31, 2013 - Development and content validation of a surgical safety
checklist for operating theatres that use robotic
technology.
July 31, 2013
Ahmed K, Khan N, Khan MS, et al. Development and content validation of a surgical safety checklist for
operating theatres that use robotic technology. BJU Int. 2013;111(7):1161-74. do…
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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…
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psnet.ahrq.gov/node/865588/psn-pdf
April 17, 2024 - Inattentional blindness in medicine.
April 17, 2024
Hults CM, Ding Y, Xie GG, et al. Inattentional blindness in medicine. Cogn Res Princ Implic. 2024;9(1):18.
doi:10.1186/s41235-024-00537-x.
https://psnet.ahrq.gov/issue/inattentional-blindness-medicine
Inattentional blindness occurs when a person is focused so int…
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psnet.ahrq.gov/node/38812/psn-pdf
April 12, 2011 - Management of test results in family medicine offices.
April 12, 2011
Elder NC, McEwen TR, Flach JM, et al. Management of test results in family medicine offices. Ann Fam
Med. 2009;7(4):343-51. doi:10.1370/afm.961.
https://psnet.ahrq.gov/issue/management-test-results-family-medicine-offices
This study evaluated co…