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psnet.ahrq.gov/node/45684/psn-pdf
January 01, 2020 - A multilevel analysis of U.S. hospital patient safety
culture relationships with perceptions of voluntary event
reporting.
June 29, 2017
Burlison JD, Quillivan RR, Kath LM, et al. A Multilevel Analysis of U.S. Hospital Patient Safety Culture
Relationships With Perceptions of Voluntary Event Reporting. J Patient Sa…
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psnet.ahrq.gov/node/40534/psn-pdf
March 23, 2012 - Association between waiting times and short term
mortality and hospital admission after departure from
emergency department: population based cohort study
from Ontario, Canada.
March 23, 2012
Guttmann A, Schull MJ, Vermeulen MJ, et al. Association between waiting times and short term mortality
and hospital admiss…
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psnet.ahrq.gov/node/44112/psn-pdf
November 03, 2015 - Unexpected death within 72 hours of emergency
department visit: were those deaths preventable?
November 3, 2015
Goulet H, Guerand V, Bloom B, et al. Unexpected death within 72 hours of emergency department visit:
were those deaths preventable? Crit Care. 2015;19(1):154. doi:10.1186/s13054-015-0877-x.
https://psnet…
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psnet.ahrq.gov/node/60314/psn-pdf
May 13, 2020 - Preparedness for COVID-19: in situ simulation to enhance
infection control systems in the intensive care unit.
May 13, 2020
Choi GYS, Wan WTP, Chan AKM, et al. Preparedness for COVID-19: in situ simulation to enhance
infection control systems in the intensive care unit. Br J Anaesth. 2020;125(2):e236-e239.
doi:10.…
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psnet.ahrq.gov/node/844790/psn-pdf
January 01, 2020 - Effectiveness of double checking to reduce medication
administration errors: a systematic review.
September 18, 2019
Koyama AK, Maddox C-SS, Li L, et al. Effectiveness of double checking to reduce medication
administration errors: a systematic review. BMJ Qual Saf. 2020;29(7):595-603. doi:10.1136/bmjqs-2019-
00955…
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psnet.ahrq.gov/node/46859/psn-pdf
January 01, 2020 - Mixed-methods evaluation of real-time safety reporting by
hospitalized patients and their care partners: the
MySafeCare application.
June 13, 2018
Collins SA, Couture B, Smith A, et al. Mixed-Methods Evaluation of Real-Time Safety Reporting by
Hospitalized Patients and Their Care Partners. J Patient Saf. 2020;16(2…
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psnet.ahrq.gov/node/45988/psn-pdf
April 24, 2018 - Translating concerns into action: a detailed qualitative
evaluation of an interdisciplinary intervention on medical
wards.
April 24, 2018
Pannick S, Archer S, Johnston MJ, et al. Translating concerns into action: a detailed qualitative evaluation
of an interdisciplinary intervention on medical wards. BMJ Open. 201…
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psnet.ahrq.gov/node/47102/psn-pdf
June 26, 2018 - Transition to a new electronic health record and pediatric
medication safety: lessons learned in pediatrics within a
large academic health system.
June 26, 2018
Whalen K, Lynch E, Moawad I, et al. Transition to a new electronic health record and pediatric medication
safety: lessons learned in pediatrics within a l…
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psnet.ahrq.gov/node/45595/psn-pdf
April 19, 2017 - Estimating deaths due to medical error: the ongoing
controversy and why it matters.
April 19, 2017
Shojania KG, Dixon-Woods M. Estimating deaths due to medical error: the ongoing controversy and why it
matters. BMJ Qual Saf. 2017;26(5):423-428. doi:10.1136/bmjqs-2016-006144.
https://psnet.ahrq.gov/issue/estimating…
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psnet.ahrq.gov/node/47736/psn-pdf
February 27, 2019 - Using a potentially aggressive/violent patient huddle to
improve health care safety.
February 27, 2019
Larson LA, Finley JL, Gross TL, et al. Using a Potentially Aggressive/Violent Patient Huddle to Improve
Health Care Safety. Jt Comm J Qual Patient Saf. 2019;45(2):74-80. doi:10.1016/j.jcjq.2018.08.011.
https://ps…
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psnet.ahrq.gov/node/45177/psn-pdf
June 01, 2016 - Quantifying the burden of opioid medication errors in
adult oncology and palliative care settings: a systematic
review.
June 1, 2016
Heneka N, Shaw T, Rowett D, et al. Quantifying the burden of opioid medication errors in adult oncology
and palliative care settings: A systematic review. Palliat Med. 2016;30(6):520…
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psnet.ahrq.gov/node/46454/psn-pdf
August 20, 2018 - First, Do No Harm: Marshaling Clinician Leadership to
Counter the Opioid Epidemic.
August 20, 2018
Adams SM, Blanco C, Chaudhry HJ, et al. Washington, DC: National Academy of Medicine; 2017. ISBN
9781947103108.
https://psnet.ahrq.gov/issue/first-do-no-harm-marshaling-clinician-leadership-counter-opioid-epidemic
M…
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psnet.ahrq.gov/node/38455/psn-pdf
January 02, 2017 - Clinical triggers: an alternative to a rapid response team.
January 2, 2017
Moldenhauer K, Sabel A, Chu ES, et al. Clinical triggers: an alternative to a rapid response team. Jt Comm
J Qual Patient Saf. 2009;35(3):164-74.
https://psnet.ahrq.gov/issue/clinical-triggers-alternative-rapid-response-team
A national cam…
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psnet.ahrq.gov/node/39839/psn-pdf
November 07, 2011 - The disparity of frontline clinical staff and managers'
perceptions of a quality and patient safety initiative.
November 7, 2011
Parand A, Burnett S, Benn J, et al. The disparity of frontline clinical staff and managers' perceptions of a
quality and patient safety initiative. J Eval Clin Pract. 2011;17(6):1184-90. …
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psnet.ahrq.gov/node/42396/psn-pdf
July 31, 2013 - Developing and implementing a standardized process for
Global Trigger Tool application across a large health
system.
July 31, 2013
Garrett PR, Sammer C, Nelson A, et al. Developing and implementing a standardized process for global
trigger tool application across a large health system. Jt Comm J Qual Saf. 2013;39(…
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psnet.ahrq.gov/node/44096/psn-pdf
November 03, 2015 - Incidence of "never events" among weekend admissions
versus weekday admissions to US hospitals: national
analysis.
November 3, 2015
Attenello FJ, Wen T, Cen SY, et al. Incidence of "never events" among weekend admissions versus
weekday admissions to US hospitals: national analysis. BMJ. 2015;350:h1460. doi:10.1136…
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psnet.ahrq.gov/node/43604/psn-pdf
October 15, 2014 - The challenges in monitoring and preventing patient
safety incidents for people with intellectual disabilities in
NHS acute hospitals: evidence from a mixed-methods
study.
October 15, 2014
Tuffrey-Wijne I, Goulding L, Gordon V, et al. The challenges in monitoring and preventing patient safety
incidents for people…
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psnet.ahrq.gov/node/38536/psn-pdf
February 03, 2011 - Association between hospital-reported Leapfrog Safe
Practices scores and inpatient mortality.
February 3, 2011
Werner RM, McNutt RA. A New Strategy to Improve Quality. JAMA. 2009;301(13).
doi:10.1001/jama.2009.423.
https://psnet.ahrq.gov/issue/association-between-hospital-reported-leapfrog-safe-practices-scores-an…
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psnet.ahrq.gov/node/44102/psn-pdf
May 06, 2015 - Factors that influence the recognition, reporting and
resolution of incidents related to medical devices and
other healthcare technologies: a systematic review.
May 6, 2015
Polisena J, Gagliardi AR, Urbach DR, et al. Factors that influence the recognition, reporting and resolution
of incidents related to medical d…
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psnet.ahrq.gov/node/39071/psn-pdf
November 04, 2009 - Identification of patient information corruption in the
intensive care unit: using a scoring tool to direct quality
improvements in handover.
November 4, 2009
Pickering BW, Hurley K, Marsh B. Identification of patient information corruption in the intensive care unit:
using a scoring tool to direct quality improve…