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psnet.ahrq.gov/node/43553/psn-pdf
August 28, 2017 - Analysis of adverse events associated with adult
moderate procedural sedation outside the operating
room.
August 28, 2017
Karamnov S, Sarkisian N, Grammer R, et al. Analysis of Adverse Events Associated With Adult Moderate
Procedural Sedation Outside the Operating Room. J Patient Saf. 2014;13(3):111-121.
doi:10.1…
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psnet.ahrq.gov/node/44709/psn-pdf
November 18, 2016 - Lost information during the handover of critically injured
trauma patients: a mixed-methods study.
November 18, 2016
Zakrison TL, Rosenbloom B, McFarlan A, et al. Lost information during the handover of critically injured
trauma patients: a mixed-methods study. BMJ Qual Saf. 2016;25(12):929-936. doi:10.1136/bmjqs-2…
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psnet.ahrq.gov/node/48130/psn-pdf
August 07, 2019 - Adverse events in long-term care residents transitioning
from hospital back to nursing home.
August 7, 2019
Kapoor A, Field T, Handler S, et al. Adverse Events in Long-term Care Residents Transitioning From
Hospital Back to Nursing Home. JAMA Intern Med. 2019;179(9):1254-1261.
doi:10.1001/jamainternmed.2019.2005.
…
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psnet.ahrq.gov/node/40024/psn-pdf
December 21, 2014 - Risk factors and outcomes for foreign body left during a
procedure: analysis of 413 incidents after 1,946,831
operations in children.
December 21, 2014
Camp M, Chang DC, Zhang Y, et al. Risk factors and outcomes for foreign body left during a procedure:
analysis of 413 incidents after 1 946 831 operations in child…
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psnet.ahrq.gov/node/45407/psn-pdf
September 27, 2016 - Safety of the Manchester Triage System to detect
critically ill children at the emergency department.
September 27, 2016
Zachariasse JM, Kuiper JW, de Hoog M, et al. Safety of the Manchester Triage System to Detect Critically
Ill Children at the Emergency Department. J Pediatr. 2016;177:232-237.e1.
doi:10.1016/j.j…
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psnet.ahrq.gov/node/41408/psn-pdf
October 19, 2012 - Patient notification for bloodborne pathogen testing due
to unsafe injection practices in the US health care
settings, 2001–2011.
October 19, 2012
Guh AY, Thompson ND, Schaefer MK, et al. Patient notification for bloodborne pathogen testing due to
unsafe injection practices in the US health care settings, 2001-201…
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psnet.ahrq.gov/node/44522/psn-pdf
June 21, 2016 - Impact of an electronic alert notification system
embedded in radiologists' workflow on closed-loop
communication of critical results: a time series analysis.
June 21, 2016
Lacson R, O'Connor SD, Sahni A, et al. Impact of an electronic alert notification system embedded in
radiologists' workflow on closed-loop com…
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psnet.ahrq.gov/node/43788/psn-pdf
February 25, 2015 - Evaluating ambulatory practice safety: the PROMISES
Project administrators and practice staff surveys.
February 25, 2015
Singer SJ, Nieva HR, Brede N, et al. Evaluating ambulatory practice safety: the PROMISES project
administrators and practice staff surveys. Med Care. 2015;53(2):141-52.
doi:10.1097/MLR.000000000…
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psnet.ahrq.gov/node/43170/psn-pdf
December 12, 2014 - Effects of patient-, environment- and medication-related
factors on high-alert medication incidents.
December 12, 2014
Manias E, Williams A, Liew D, et al. Effects of patient-, environment- and medication-related factors on
high-alert medication incidents. Int J Qual Health Care. 2014;26(3):308-20. doi:10.1093/intq…
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psnet.ahrq.gov/node/46975/psn-pdf
November 16, 2018 - Electronic health record usability issues and potential
contribution to patient harm.
November 16, 2018
Howe JL, Adams KT, Hettinger Z, et al. Electronic Health Record Usability Issues and Potential
Contribution to Patient Harm. JAMA. 2018;319(12):1276-1278. doi:10.1001/jama.2018.1171.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/46806/psn-pdf
January 01, 2020 - Examining the relationship of an all-cause harm patient
safety measure and critical performance measures at the
frontline of care.
February 28, 2018
Sammer C, Hauck L, Jones C, et al. Examining the Relationship of an All-Cause Harm Patient Safety
Measure and Critical Performance Measures at the Frontline of Care. …
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psnet.ahrq.gov/node/46232/psn-pdf
February 10, 2018 - Implications of electronic health record downtime: an
analysis of patient safety event reports.
February 10, 2018
Larsen E, Fong A, Wernz C, et al. Implications of electronic health record downtime: an analysis of patient
safety event reports. J Am Med Inform Assoc. 2018;25(2):187-191. doi:10.1093/jamia/ocx057.
ht…
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psnet.ahrq.gov/node/41967/psn-pdf
May 10, 2013 - A comparative review of patient safety initiatives for
national health information technology.
May 10, 2013
Magrabi F, Aarts J, Nohr C, et al. A comparative review of patient safety initiatives for national health
information technology. Int J Med Inform. 2013;82(5):e139-48. doi:10.1016/j.ijmedinf.2012.11.014.
htt…
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psnet.ahrq.gov/node/44427/psn-pdf
October 13, 2015 - Problem list completeness in electronic health records: a
multi-site study and assessment of success factors.
October 13, 2015
Wright A, McCoy AB, Hickman T-TT, et al. Problem list completeness in electronic health records: A multi-
site study and assessment of success factors. Int J Med Inform. 2015;84(10):784-90.…
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psnet.ahrq.gov/node/60248/psn-pdf
April 22, 2020 - Circumstances involved in unsupervised solid dose
medication exposures among young children.
April 22, 2020
Agarwal M, Lovegrove MC, Geller RJ, et al. Circumstances involved in unsupervised solid dose medication
exposures among young children. J Pediatr. 2020;219. doi:10.1016/j.jpeds.2019.12.027.
https://psnet.ahr…
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psnet.ahrq.gov/node/41446/psn-pdf
June 13, 2012 - Concept and development of a discharge alert filter for
abnormal laboratory values coupled with computerized
provider order entry: a tool for quality improvement and
hospital risk management.
June 13, 2012
Mathew G, Kho A, Dexter P, et al. Concept and development of a discharge alert filter for abnormal
laborator…
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psnet.ahrq.gov/node/43590/psn-pdf
October 08, 2014 - Disentangling quality and safety indicator data: a
longitudinal, comparative study of hand hygiene
compliance and accreditation outcomes in 96 Australian
hospitals.
October 8, 2014
Mumford V, Greenfield D, Hogden A, et al. Disentangling quality and safety indicator data: a longitudinal,
comparative study of hand …
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psnet.ahrq.gov/node/40946/psn-pdf
January 19, 2012 - Effects of a multicentre teamwork and communication
programme on patient outcomes: results from the Triad
for Optimal Patient Safety (TOPS) project.
January 19, 2012
Auerbach AD, Sehgal NL, Blegen MA, et al. Effects of a multicentre teamwork and communication
programme on patient outcomes: results from the Triad f…
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psnet.ahrq.gov/node/47752/psn-pdf
May 29, 2019 - How do nurses use early warning scoring systems to
detect and act on patient deterioration to ensure patient
safety? A scoping review.
May 29, 2019
Wood C, Chaboyer W, Carr P. How do nurses use early warning scoring systems to detect and act on
patient deterioration to ensure patient safety? A scoping review. Int …
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psnet.ahrq.gov/node/41212/psn-pdf
March 14, 2012 - A comprehensive overview of medical error in hospitals
using incident-reporting systems, patient complaints and
chart review of inpatient deaths.
March 14, 2012
de Feijter JM, de Grave WS, Muijtjens AM, et al. A comprehensive overview of medical error in hospitals
using incident-reporting systems, patient complain…