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psnet.ahrq.gov/issue/critical-incident-monitoring-paediatric-and-adult-critical-care-reporting-improved-patient
January 22, 2016 - Review
Critical incident monitoring in paediatric and adult critical care: from reporting to improved patient outcomes?
Citation Text:
Frey B, Schwappach DLB. Critical incident monitoring in paediatric and adult critical care: from reporting to improved patient outcomes? Curr Opin Crit…
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psnet.ahrq.gov/issue/personal-digital-assistant-based-drug-information-sources-potential-improve-medication-safety
July 14, 2010 - Study
Personal digital assistant-based drug information sources: potential to improve medication safety.
Citation Text:
Galt K, Rule AM, Houghton B, et al. Personal digital assistant-based drug information sources: potential to improve medication safety. J Med Libr Assoc. 2005;93(2):22…
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psnet.ahrq.gov/issue/improving-patient-safety-critical-care-big-challenge-exciting-opportunitylamelioration-de-la
December 22, 2018 - Commentary
Improving patient safety in critical care: big challenge, exciting opportunity/L'amelioration de la securite des patients a l'unite des soins intensifs : un grand defi, une occasion stimulante.
Citation Text:
Dodek P. Improving patient safety in critical care: big challenge,…
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psnet.ahrq.gov/issue/sins-omission-getting-too-little-medical-care-may-be-greatest-threat-patient-safety
March 06, 2005 - Study
Sins of omission. Getting too little medical care may be the greatest threat to patient safety.
Citation Text:
Hayward RA, Asch SM, Hogan MM, et al. Sins of omission: getting too little medical care may be the greatest threat to patient safety. J Gen Intern Med. 2005;20(8):686-91…
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psnet.ahrq.gov/issue/getting-underuse-interpreters-resident-physicians
February 21, 2018 - Study
Getting by: underuse of interpreters by resident physicians.
Citation Text:
Diamond LC, Schenker Y, Curry LA, et al. Getting by: underuse of interpreters by resident physicians. J Gen Intern Med. 2009;24(2):256-62. doi:10.1007/s11606-008-0875-7.
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psnet.ahrq.gov/issue/medication-errors-neonatal-and-paediatric-intensive-care-units
February 03, 2011 - Study
Classic
Medication errors in neonatal and paediatric intensive-care units.
Citation Text:
Raju TN, Kecskes S, Thornton JP, et al. Medication errors in neonatal and paediatric intensive-care units. Lancet. 1989;2(8659):374-6.
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psnet.ahrq.gov/issue/medication-safety-operating-room-survey-preparation-methods-and-drug-concentration
December 22, 2018 - Study
Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States.
Citation Text:
Shaw RE, Litman RS. Medication Safety in the Operating Room: A Survey of Preparation Methods and Drug Concentra…
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psnet.ahrq.gov/periodic-issue/periodic-issue-470
December 31, 2024 - January 15, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
November 21, 2018 - The Physical Environment: An Often Unconsidered Patient Safety Tool
Anjali Joseph, PhD, EDAC; Eileen B. Malone, RN, MSN, MS, EDAC | October 1, 2012
View more articles from the same authors.
Citation Text:
Joseph A, Malone EB. The Physical Environment: An Often Unc…
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psnet.ahrq.gov/node/49794/psn-pdf
May 01, 2017 - Communication Error in a Closed ICU
May 1, 2017
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/communication-error-closed-icu
The Case
A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney
transplant), co…
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psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-home-residents
July 23, 2024 - Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents
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July 28, 2021
Innovation
Contact
…
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psnet.ahrq.gov/node/837848/psn-pdf
August 17, 2022 - Health care quality and safety in a correctional system:
creating goals and performance measures for
improvement.
August 17, 2022
Neely J, Sampath R, Kirkbride G, et al. Health care quality and safety in a correctional system: creating
goals and performance measures for improvement. J Correct Health Care. 2022;28(…
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psnet.ahrq.gov/node/41643/psn-pdf
September 05, 2012 - A Randomized Field Study of a Leadership WalkRounds-
Based Intervention.
September 5, 2012
Tucker AL, Singer SJ. Cambridge, MA: Harvard Business School; June 25, 2012. HBS Working Paper No.
12-113.
https://psnet.ahrq.gov/issue/randomized-field-study-leadership-walkrounds-based-intervention
Leadership WalkRounds h…
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psnet.ahrq.gov/node/45943/psn-pdf
March 15, 2017 - Identifying and reducing complications after emergency
room discharge.
March 15, 2017
Hofmann PB, Bagian JP. Patient Saf Qual Healthc. February 20, 2017.
https://psnet.ahrq.gov/issue/identifying-and-reducing-complications-after-emergency-room-discharge
Emergency departments are complex environments that harbor fac…
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psnet.ahrq.gov/node/45570/psn-pdf
December 07, 2016 - Getting the Board on Board: What Your Board Needs to
Know About Quality and Safety, Third Edition.
December 7, 2016
Oak Brook, IL; Joint Commission; 2016. ISBN: 9781599409412.
https://psnet.ahrq.gov/issue/getting-board-board-what-your-board-needs-know-about-quality-and-safety-
third-edition
Engaging hospital lead…
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psnet.ahrq.gov/node/38157/psn-pdf
October 22, 2008 - Contributing factors identified by hospital incident report
narratives.
October 22, 2008
Nuckols TK, Bell DS, Paddock SM, et al. Contributing factors identified by hospital incident report
narratives. Qual Saf Health Care. 2008;17(5):368-72. doi:10.1136/qshc.2007.023721.
https://psnet.ahrq.gov/issue/contributing-f…
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psnet.ahrq.gov/node/45563/psn-pdf
October 19, 2016 - Using a change model to reduce the risk of surgical site
infection.
October 19, 2016
Burden M. Using a change model to reduce the risk of surgical site infection. Br J Nurs. 2016;25(17):949-
955.
https://psnet.ahrq.gov/issue/using-change-model-reduce-risk-surgical-site-infection
Surgical site infections can resul…
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psnet.ahrq.gov/node/37026/psn-pdf
September 15, 2011 - Residents feel unprepared and unsupervised as leaders
of cardiac arrest teams in teaching hospitals: a survey of
internal medicine residents.
September 15, 2011
Hayes CW, Rhee A, Detsky ME, et al. Residents feel unprepared and unsupervised as leaders of cardiac
arrest teams in teaching hospitals: a survey of inter…
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psnet.ahrq.gov/node/60235/psn-pdf
April 15, 2020 - Independent Mortality Review of Cardiac Surgery at St
George’s University Hospitals NHS Foundation Trust.
April 15, 2020
NHS Improvement. Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals
NHS Foundation Trust. NHS England. March 2020.
https://psnet.ahrq.gov/issue/independent-morta…
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psnet.ahrq.gov/node/35218/psn-pdf
August 07, 2018 - Building a Memory: Preventing Harm, Reducing Risks and
Improving Patient Safety.
August 7, 2018
Scobie S, Thomson R. London, UK : National Patient Safety Agency; 2005.
https://psnet.ahrq.gov/issue/building-memory-preventing-harm-reducing-risks-and-improving-patient-safety
Created in 2001 to institute changes in he…