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psnet.ahrq.gov/node/39177/psn-pdf
May 04, 2010 - The impact of organisational and individual factors on
team communication in surgery: a qualitative study.
May 4, 2010
Gillespie BM, Chaboyer W, Longbottom P, et al. The impact of organisational and individual factors on
team communication in surgery: a qualitative study. Int J Nurs Stud. 2010;47(6):732-41.
doi:10…
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psnet.ahrq.gov/node/41799/psn-pdf
December 29, 2014 - Types and patterns of safety concerns in home care: staff
perspectives.
December 29, 2014
Craven CK, Byrne K, Sims-Gould J, et al. Types and patterns of safety concerns in home care: staff
perspectives. Int J Qual Health Care. 2012;24(5):525-31. doi:10.1093/intqhc/mzs047.
https://psnet.ahrq.gov/issue/types-and-pat…
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psnet.ahrq.gov/node/36381/psn-pdf
April 22, 2011 - Accountability sought by patients following adverse
events from medical care: the New Zealand experience.
April 22, 2011
Bismark M, Dauer E, Paterson R, et al. Accountability sought by patients following adverse events from
medical care: the New Zealand experience. CMAJ. 2006;175(8):889-94.
https://psnet.ahrq.gov/…
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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/42767/psn-pdf
November 27, 2013 - Barcode medication administration work-arounds: a
systematic review and implications for nurse executives.
November 27, 2013
Voshall B, Piscotty R, Lawrence J, et al. Barcode medication administration work-arounds: a systematic
review and implications for nurse executives. J Nurs Adm. 2013;43(10):530-535.
doi:10.1…
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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/73989/psn-pdf
October 20, 2021 - How is safety climate measured? A review and evaluation.
October 20, 2021
Shea T, De Cieri H, Vu T, et al. How is safety climate measured? A review and evaluation. Safety Sci.
2021;143:105413. doi:10.1016/j.ssci.2021.105413.
https://psnet.ahrq.gov/issue/how-safety-climate-measured-review-and-evaluation
Assessing s…
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psnet.ahrq.gov/node/40274/psn-pdf
December 29, 2014 - Predictors of the perceived impact of a patient safety
collaborative: an exploratory study.
December 29, 2014
Pinto A, Benn J, Burnett S, et al. Predictors of the perceived impact of a patient safety collaborative: an
exploratory study. Int J Qual Health Care. 2011;23(2):173-81. doi:10.1093/intqhc/mzq089.
https://…
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psnet.ahrq.gov/node/36536/psn-pdf
January 10, 2011 - What do family physicians consider an error? A
comparison of definitions and physician perception.
January 10, 2011
Elder NC, Pallerla H, Regan S. What do family physicians consider an error? A comparison of definitions
and physician perception. BMC Fam Pract. 2006;7:73.
https://psnet.ahrq.gov/issue/what-do-family…
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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/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/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/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/35196/psn-pdf
March 01, 2011 - A method for measuring system safety and latent errors
associated with pediatric procedural sedation.
March 1, 2011
Blike G, Christoffersen K, Cravero JP, et al. A method for measuring system safety and latent errors
associated with pediatric procedural sedation. Anesth Analg. 2005;101(1):48-58, table of contents.
…
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psnet.ahrq.gov/node/38305/psn-pdf
January 15, 2009 - High-alert medications in the pediatric intensive care unit.
January 15, 2009
Franke HA, Woods D, Holl JL. High-alert medications in the pediatric intensive care unit. Pediatr Crit Care
Med. 2009;10(1):85-90. doi:10.1097/PCC.0b013e3181936ff8.
https://psnet.ahrq.gov/issue/high-alert-medications-pediatric-intensive-c…
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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/38846/psn-pdf
August 05, 2009 - Seeking a safer surgery: some states crack down on
doctors who perform unregulated outpatient procedures.
August 5, 2009
Landro L.
https://psnet.ahrq.gov/issue/seeking-safer-surgery-some-states-crack-down-doctors-who-perform-
unregulated-outpatient
This article discusses growing legal oversight on outpatient surg…
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psnet.ahrq.gov/node/43934/psn-pdf
September 27, 2017 - Communication elements supporting patient safety in
psychiatric inpatient care.
September 27, 2017
Kanerva A, Kivinen T, Lammintakanen J. Communication elements supporting patient safety in psychiatric
inpatient care. J Psychiatr Ment Health Nurs. 2015;22(5):298-305. doi:10.1111/jpm.12187.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/42209/psn-pdf
April 24, 2013 - Analysis of staff safety concerns.
April 24, 2013
Davidson J, Lamontagne G, Burnell L, et al. Analysis of Staff Safety Concerns. J Nurs Care Qual.
2012;28(2). doi:10.1097/ncq.0b013e318277e874.
https://psnet.ahrq.gov/issue/analysis-staff-safety-concerns
This case study demonstrates how an organization used a safety…
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psnet.ahrq.gov/node/39954/psn-pdf
November 26, 2014 - Incidence of adverse drug events and medication errors
in Japan: the JADE Study.
November 26, 2014
Sakuma M, Bates DW, Morimoto T. Clinical prediction rule to identify high-risk inpatients for adverse drug
events: the JADE Study. Pharmacoepidemiol Drug Saf. 2012;21(11). doi:10.1002/pds.3331.
https://psnet.ahrq.gov…