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psnet.ahrq.gov/node/47055/psn-pdf
May 23, 2018 - Surgical checklists save lives—but once in a while, they
don't. Why?
May 23, 2018
Mukherjee S. New York Times Magazine. May 9, 2018.
https://psnet.ahrq.gov/issue/surgical-checklists-save-lives-once-while-they-dont-why
Checklists can coordinate action and communication to augment safety, but human and system factor…
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psnet.ahrq.gov/node/39275/psn-pdf
February 03, 2010 - Medical librarians supporting information systems project
lifecycles toward improved patient safety.
February 3, 2010
Saimbert MK, Zhang Y, Pierce J, et al. Medical librarians supporting information systems project lifecycles
toward improved patient safety. Medical librarians possess expertise to navigate various s…
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psnet.ahrq.gov/node/60020/psn-pdf
March 04, 2020 - The eNOTSS platform for surgeons’ nontechnical skills
performance improvement.
March 4, 2020
Pradarelli JC, Yule S, Smink DS. The eNOTSS Platform for Surgeons’ Nontechnical Skills Performance
Improvement. JAMA Surg. 2020;155(5):438-439. doi:10.1001/jamasurg.2019.5880.
https://psnet.ahrq.gov/issue/enotss-platform-s…
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psnet.ahrq.gov/node/44046/psn-pdf
August 21, 2015 - Development of an instrument to measure the unintended
consequences of EHRs.
August 21, 2015
Carrington JM, Gephart SM, Verran JA, et al. Development of an Instrument to Measure the Unintended
Consequences of EHRs. West J Nurs Res. 2015;37(7):842-58. doi:10.1177/0193945915576083.
https://psnet.ahrq.gov/issue/devel…
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psnet.ahrq.gov/node/41718/psn-pdf
October 03, 2012 - Duty hours, quality of care, and patient safety: general
surgery resident perceptions.
October 3, 2012
Borman KR, Jones AT, Shea JA. Duty hours, quality of care, and patient safety: general surgery resident
perceptions. J Am Coll Surg. 2012;215(1):70-7; discussion 77-9. doi:10.1016/j.jamcollsurg.2012.02.010.
https…
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psnet.ahrq.gov/node/39517/psn-pdf
May 25, 2010 - A prospective controlled trial of the effect of a multi-
faceted intervention on early recognition and intervention
in deteriorating hospital patients.
May 25, 2010
Mitchell IA, McKay H, Van Leuvan C, et al. A prospective controlled trial of the effect of a multi-faceted
intervention on early recognition and inter…
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psnet.ahrq.gov/node/866285/psn-pdf
October 30, 2023 - Executive Order on the Safe, Secure, and Trustworthy
Development and Use of Artificial Intelligence.
October 30, 2023
Washington DC: The White House; October 30, 2023. EO 14110.
https://psnet.ahrq.gov/issue/executive-order-safe-secure-and-trustworthy-development-and-use-artificial-
intelligence
Artificial in…
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psnet.ahrq.gov/node/35182/psn-pdf
April 11, 2011 - Standard drug concentrations and smart-pump
technology reduce continuous-medication-infusion errors
in pediatric patients.
April 11, 2011
Larsen G, Parker HB, Cash J, et al. Standard drug concentrations and smart-pump technology reduce
continuous-medication-infusion errors in pediatric patients. Pediatrics. 2005;1…
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psnet.ahrq.gov/node/46650/psn-pdf
July 12, 2018 - Towards a more patient-centered approach to medication
safety.
July 12, 2018
Lee JL, Dy SM, Gurses AP, et al. Towards a More Patient-Centered Approach to Medication Safety. J
Patient Exp. 2018;5(2):83-87. doi:10.1177/2374373517727532.
https://psnet.ahrq.gov/issue/towards-more-patient-centered-approach-medication-s…
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psnet.ahrq.gov/node/41975/psn-pdf
February 01, 2013 - Impact of an intensivist-led multidisciplinary extended
rapid response team on hospital-wide cardiopulmonary
arrests and mortality.
February 1, 2013
Al-Qahtani S, Al-Dorzi HM, Tamim HM, et al. Impact of an intensivist-led multidisciplinary extended rapid
response team on hospital-wide cardiopulmonary arrests and m…
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psnet.ahrq.gov/node/48006/psn-pdf
May 15, 2019 - Limits on opioid prescribing leave patients with chronic
pain vulnerable.
May 15, 2019
Rubin R. Limits on Opioid Prescribing Leave Patients With Chronic Pain Vulnerable. JAMA.
2019;321(21):2059-2062. doi:10.1001/jama.2019.5188.
https://psnet.ahrq.gov/issue/limits-opioid-prescribing-leave-patients-chronic-pain-vuln…
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psnet.ahrq.gov/node/41952/psn-pdf
January 16, 2013 - Prevention of a wrong-location misadministration through
the use of an intradepartmental incident learning system.
January 16, 2013
Ford E, Smith K, Harris K, et al. Prevention of a wrong-location misadministration through the use of an
intradepartmental incident learning system. Med Phys. 2012;39(11):6968-71. doi:…
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psnet.ahrq.gov/node/74011/psn-pdf
October 27, 2021 - Dashboards for visual display of patient safety data: a
systematic review.
October 27, 2021
Murphy DR, Savoy A, Satterly T, et al. Dashboards for visual display of patient safety data: a systematic
review. BMJ Health Care Inform. 2021;28(1):e100437. doi:10.1136/bmjhci-2021-100437.
https://psnet.ahrq.gov/issue/dash…
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psnet.ahrq.gov/node/35253/psn-pdf
April 06, 2011 - Real time patient safety audits: improving safety every
day.
April 6, 2011
Ursprung R. Real time patient safety audits: improving safety every day. Qual Saf Health Care.
2005;14(4):284-289. doi:10.1136/qshc.2004.012542.
https://psnet.ahrq.gov/issue/real-time-patient-safety-audits-improving-safety-every-day
This p…
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psnet.ahrq.gov/node/836856/psn-pdf
April 06, 2022 - To what extent are patients involved in researching safety
in acute mental healthcare?
April 6, 2022
Brierley-Jones L, Ramsey L, Canvin K, et al. To what extent are patients involved in researching safety in
acute mental healthcare? Res Involv Engagem. 2022;8(1):8. doi:10.1186/s40900-022-00337-x.
https://psnet.ahr…
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psnet.ahrq.gov/node/47810/psn-pdf
March 13, 2019 - Debriefing in the OR: a quality improvement project.
March 13, 2019
Finch EP, Langston M, Erickson D, et al. Debriefing in the OR: A Quality Improvement Project. AORN J.
2019;109(3):336-344. doi:10.1002/aorn.12616.
https://psnet.ahrq.gov/issue/debriefing-or-quality-improvement-project
Debriefing has emerged as a s…
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psnet.ahrq.gov/node/34797/psn-pdf
October 06, 2015 - Adapting to new technologies in the operating room.
October 6, 2015
Cook RI, Woods DD. Adapting to New Technology in the Operating Room. Hum Factors. 2006;38(4):593-
613. doi:10.1518/001872096778827224.
https://psnet.ahrq.gov/issue/adapting-new-technologies-operating-room
New technology continues to offer great ad…
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psnet.ahrq.gov/node/47009/psn-pdf
December 21, 2018 - Perceptions of rounding checklists in the intensive care
unit: a qualitative study.
December 21, 2018
Hallam BD, Kuza CC, Rak K, et al. Perceptions of rounding checklists in the intensive care unit: a
qualitative study. BMJ Qual Saf. 2018;27(10):836-843. doi:10.1136/bmjqs-2017-007218.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/73592/psn-pdf
August 11, 2021 - Using performance improvement to enhance time-out
compliance and prevent wrong-site surgery.
August 11, 2021
Vance ME, Proctor T, Schmidt KA. Using performance improvement to enhance time-out compliance and
prevent wrong-site surgery. AORN J. 2021;113(6):635-642. doi:10.1002/aorn.13413.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/45373/psn-pdf
November 18, 2016 - Prevalence, risk factors, and outcomes of idle
intravenous catheters: an integrative review.
November 18, 2016
Becerra MB, Shirley D, Safdar N. Prevalence, risk factors, and outcomes of idle intravenous catheters: An
integrative review. Am J Infect Control. 2016;44(10):e167-e172. doi:10.1016/j.ajic.2016.03.073.
ht…