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psnet.ahrq.gov/node/38785/psn-pdf
September 02, 2009 - An ethnographic study of classifying and accounting for
risk at the sharp end of medical wards.
September 2, 2009
Dixon-Woods M, Suokas A, Pitchforth E, et al. An ethnographic study of classifying and accounting for risk
at the sharp end of medical wards. Soc Sci Med. 2009;69(3):362-9. doi:10.1016/j.socscimed.2009.…
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psnet.ahrq.gov/node/39814/psn-pdf
January 28, 2015 - Patient safety for global health - developing safe, effective
and accessible technologies.
January 28, 2015
Qual Saf Health Care. 2010;19(suppl 2):i1-i47.
https://psnet.ahrq.gov/issue/patient-safety-global-health-developing-safe-effective-and-accessible-
technologies
This supplement provides the conclusions of wo…
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psnet.ahrq.gov/node/43864/psn-pdf
January 28, 2015 - Starter Kit for Alarm Fatigue.
January 28, 2015
National Association of Clinical Nurse Specialists; NACNS.
https://psnet.ahrq.gov/issue/starter-kit-alarm-fatigue
Alarm fatigue has been identified as a serious problem that affects the safety of nursing care. This toolkit
provides checklists, resources, and implemen…
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psnet.ahrq.gov/node/43086/psn-pdf
March 26, 2014 - International Comparisons: A Focus on Quality of Care.
March 26, 2014
Ottawa, ON: Canadian Institute for Health Information; January 23, 2014.
https://psnet.ahrq.gov/issue/international-comparisons-focus-quality-care
This report compared the quality of care in Canada with 34 other countries to identify areas in whi…
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psnet.ahrq.gov/node/43241/psn-pdf
June 11, 2014 - "It is the left eye, right?"
June 11, 2014
Pikkel D, Sharabi-Nov A, Pikkel J. "It is the left eye, right?". Risk Manag Healthc Policy. 2014;7:77-80.
doi:10.2147/RMHP.S60728.
https://psnet.ahrq.gov/issue/it-left-eye-right
In this study, cataract surgeons were asked to identify the correct eye for surgery when given…
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psnet.ahrq.gov/node/41631/psn-pdf
September 24, 2016 - Interruption handling strategies during paediatric
medication administration.
September 24, 2016
Colligan L, Bass EJ. Interruption handling strategies during paediatric medication administration. BMJ Qual
Saf. 2012;21(11):912-7. doi:10.1136/bmjqs-2011-000292.
https://psnet.ahrq.gov/issue/interruption-handling-stra…
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psnet.ahrq.gov/node/42910/psn-pdf
July 28, 2014 - Feeling safe during an inpatient hospitalization: a concept
analysis.
July 28, 2014
Mollon D. Feeling safe during an inpatient hospitalization: a concept analysis. J Adv Nurs.
2014;70(8):1727-37. doi:10.1111/jan.12348.
https://psnet.ahrq.gov/issue/feeling-safe-during-inpatient-hospitalization-concept-analysis
Thi…
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psnet.ahrq.gov/node/41603/psn-pdf
August 22, 2012 - Nurse–pharmacist collaboration on medication
reconciliation prevents potential harm.
August 22, 2012
Feldman LS, Costa LL, Feroli R, et al. Nurse-pharmacist collaboration on medication reconciliation
prevents potential harm. J Hosp Med. 2012;7(5):396-401. doi:10.1002/jhm.1921.
https://psnet.ahrq.gov/issue/nurse-ph…
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psnet.ahrq.gov/node/39643/psn-pdf
December 21, 2014 - A systematic quantitative assessment of risks associated
with poor communication in surgical care.
December 21, 2014
Nagpal K, Vats A, Ahmed K, et al. A systematic quantitative assessment of risks associated with poor
communication in surgical care. Arch Surg. 2010;145(6):582-8. doi:10.1001/archsurg.2010.105.
http…
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psnet.ahrq.gov/node/36745/psn-pdf
March 10, 2011 - Reevaluating recovery: perceived violations and
preemptive interventions on emergency psychiatry
rounds.
March 10, 2011
Cohen T, Blatter B, Almeida C, et al. Reevaluating recovery: perceived violations and preemptive
interventions on emergency psychiatry rounds. J Am Med Inform Assoc. 2007;14(3):312-9.
https://ps…
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psnet.ahrq.gov/node/39500/psn-pdf
January 03, 2017 - Using in situ simulation to improve in-hospital
cardiopulmonary resuscitation.
January 3, 2017
Lighthall GK, Poon T, Harrison K. Using in situ simulation to improve in-hospital cardiopulmonary
resuscitation. Jt Comm J Qual Patient Saf. 2010;36(5):209-16.
https://psnet.ahrq.gov/issue/using-situ-simulation-improve-h…
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psnet.ahrq.gov/node/41013/psn-pdf
January 01, 2012 - Patient safety in emergency medical services: a
systematic review of the literature.
December 21, 2011
Bigham BL, Buick JE, Brooks SC, et al. Patient safety in emergency medical services: a systematic review
of the literature. Prehosp Emerg Care. 2012;16(1):20-35. doi:10.3109/10903127.2011.621045.
https://psnet.ah…
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psnet.ahrq.gov/node/40115/psn-pdf
January 05, 2011 - Infection control hazards and near misses reported by
nursing students.
January 5, 2011
Geller NF, Bakken S, Currie LM, et al. Infection control hazards and near misses reported by nursing
students. Am J Infect Control. 2010;38(10):811-6. doi:10.1016/j.ajic.2010.06.001.
https://psnet.ahrq.gov/issue/infection-contr…
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psnet.ahrq.gov/node/36446/psn-pdf
March 28, 2011 - Healthcare provider complaints to the emergency
department: a preliminary report on a new quality
improvement instrument.
March 28, 2011
Griffey RT, Bohan JS. Healthcare provider complaints to the emergency department: a preliminary report
on a new quality improvement instrument. Qual Saf Health Care. 2006;15(5):3…
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psnet.ahrq.gov/node/846765/psn-pdf
March 29, 2023 - Addressing Medical Gaslighting to Improve Maternal
Health—Together.
March 29, 2023
Oregon Patient Safety Commission: 2023.
https://psnet.ahrq.gov/issue/addressing-medical-gaslighting-improve-maternal-health-together
Gaslighting has been identified as a contributor to maternal mortality and morbidity. This toolkit …
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psnet.ahrq.gov/node/39262/psn-pdf
March 04, 2011 - Unintended errors with EHR-based result management: a
case series.
March 4, 2011
Yackel TR, Embi P. Unintended errors with EHR-based result management: a case series. J Am Med
Inform Assoc. 2010;17(1):104-7. doi:10.1197/jamia.M3294.
https://psnet.ahrq.gov/issue/unintended-errors-ehr-based-result-management-case-se…
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psnet.ahrq.gov/glossary/forcing-function
September 13, 2021 - Forcing Function
September 13, 2021
Anonymous (not verified)
An aspect of a design that prevents a target action from being performed or allows its performance only if another specific action is performed first. For example, automobiles are now designed so that the driver cannot shift into reverse without first…
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psnet.ahrq.gov/node/40728/psn-pdf
October 21, 2011 - What prevents incident disclosure, and what can be done
to promote it?
October 21, 2011
Iedema R, Allen S, Sorensen R, et al. What prevents incident disclosure, and what can be done to promote
it? Jt Comm J Qual Patient Saf. 2011;37(9):409-417.
https://psnet.ahrq.gov/issue/what-prevents-incident-disclosure-and-wha…
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psnet.ahrq.gov/node/35426/psn-pdf
September 15, 2009 - Medical malpractice in the People's Republic of China: the
2002 regulation on the handling of medical accidents.
September 15, 2009
Harris DM, Wu C-C. Medical malpractice in the People's Republic of China: the 2002 Regulation on the
Handling of Medical Accidents. J Law Med Ethics. 2005;33(3):456-77.
https://psnet.…
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psnet.ahrq.gov/node/50664/psn-pdf
November 13, 2019 - Drug Shortages: Root Causes and Potential Solutions.
November 13, 2019
Drug Shortage Task Force. Silver Spring, MD: US Food and Drug Administration; 2020.
https://psnet.ahrq.gov/issue/drug-shortages-root-causes-and-potential-solutions
Drug shortages result from a variety of systemic failures. This report identifies…