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psnet.ahrq.gov/node/47963/psn-pdf
June 02, 2019 - Evidence and efficacy: time to think beyond the
traditional randomised controlled trial in patient safety
studies.
June 2, 2019
Webster CS. Evidence and efficacy: time to think beyond the traditional randomised controlled trial in
patient safety studies. Br J Anaesth. 2019;122(6):723-725. doi:10.1016/j.bja.2019.02…
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psnet.ahrq.gov/node/72481/psn-pdf
November 18, 2020 - Computer-based simulation to reduce EHR-related
chemotherapy ordering errors.
November 18, 2020
Wyatt KD, Freedman EB, Arteaga GM, et al. Computer?based simulation to reduce EHR?related
chemotherapy ordering errors. Cancer Med. 2020;9(23):8844-8851. doi:10.1002/cam4.3496.
https://psnet.ahrq.gov/issue/computer-base…
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psnet.ahrq.gov/node/42191/psn-pdf
June 25, 2013 - Chemotherapy medication errors in a pediatric cancer
treatment center: prospective characterization of error
types and frequency and development of a quality
improvement initiative to lower the error rate.
June 25, 2013
Watts RG, Parsons K. Chemotherapy medication errors in a pediatric cancer treatment center: pro…
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psnet.ahrq.gov/node/60891/psn-pdf
September 09, 2020 - Using the NAM diagnostic process framework to teach
clinical reasoning in computerized case presentations to
251 medical students.
September 9, 2020
Covin Y, Longo P, Wick N, et al. Using the NAM diagnostic process framework to teach clinical reasoning
in computerized case presentations to 251 medical students. Di…
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psnet.ahrq.gov/node/46964/psn-pdf
April 11, 2018 - The gaps in specialists' diagnoses.
April 11, 2018
Scott IA, Campbell DA. The gaps in specialists' diagnoses. Med J Aust. 2018;208(5):196-197.
https://psnet.ahrq.gov/issue/gaps-specialists-diagnoses
Leaders in the effort to improve diagnosis have heralded diagnosis as a team activity. This commentary
suggests that…
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psnet.ahrq.gov/node/46922/psn-pdf
January 01, 2019 - Reducing interdisciplinary communication failures
through secure text messaging: a quality improvement
project.
March 21, 2018
Hansen JE, Lazow M, Hagedorn PA. Reducing Interdisciplinary Communication Failures Through Secure
Text Messaging. Pediatr Qual Saf. 2019;3(1). doi:10.1097/pq9.0000000000000053.
https://ps…
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psnet.ahrq.gov/node/50744/psn-pdf
December 18, 2019 - EMS crews brought patients to the hospital with
misplaced breathing tubes. None of them survived
December 18, 2019
Arditi L. Peoples Public Radio. December 3, 2019.
https://psnet.ahrq.gov/issue/ems-crews-brought-patients-hospital-misplaced-breathing-tubes-none-them-
survived
Emergency medical services are often p…
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psnet.ahrq.gov/node/36529/psn-pdf
August 09, 2011 - 5 Million Lives Campaign.
August 9, 2011
Institute for Healthcare Improvement; IHI
https://psnet.ahrq.gov/issue/5-million-lives-campaign
The Institute for Healthcare Improvement's 100,000 Lives Campaign successfully engaged more than
3,000 US hospitals in a coordinated effort to reduce preventable inpatient deaths…
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psnet.ahrq.gov/node/849326/psn-pdf
May 24, 2023 - Proactive patient safety: focusing on what goes right in
the perioperative environment.
May 24, 2023
Duffy C, Menon N, Horak D, et al. Proactive patient safety: focusing on what goes right in the perioperative
environment. J Patient Saf. 2023;19(4):281-286. doi:10.1097/pts.0000000000001113.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/44548/psn-pdf
November 20, 2015 - Safety-II and resilience: the way ahead in patient safety in
anaesthesiology.
November 20, 2015
Staender S. Safety-II and resilience: the way ahead in patient safety in anaesthesiology. Curr Opin
Anaesthesiol. 2015;28(6):735-9. doi:10.1097/ACO.0000000000000252.
https://psnet.ahrq.gov/issue/safety-ii-and-resilience…
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psnet.ahrq.gov/node/843087/psn-pdf
January 25, 2023 - Interventions to increase patient safety in long-term care
facilities-umbrella review.
January 25, 2023
?witalski J, Wnuk K, Tatara T, et al. Interventions to increase patient safety in long-term care facilities-
umbrella review. Int J Environ Res Public Health. 2022;19(22):15354. doi:10.3390/ijerph192215354.
http…
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psnet.ahrq.gov/node/47217/psn-pdf
June 27, 2018 - Drug shortages roundtable: minimizing the impact on
patient care.
June 27, 2018
Drug shortages roundtable: Minimizing the impact on patient care. Am J Health Syst Pharm.
2018;75(11):816-820. doi:10.2146/ajhp180048.
https://psnet.ahrq.gov/issue/drug-shortages-roundtable-minimizing-impact-patient-care
This commenta…
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psnet.ahrq.gov/node/45325/psn-pdf
April 08, 2018 - Diagnosis is a team sport—partnering with allied health
professionals to reduce diagnostic errors: a case study
on the role of a vestibular therapist in diagnosing
dizziness.
April 8, 2018
Thomas DB, Newman-Toker DE. Diagnosis is a team sport - partnering with allied health professionals to
reduce diagnostic erro…
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psnet.ahrq.gov/node/47888/psn-pdf
May 11, 2019 - Achieving dialysis safety: the critical role of higher-
functioning teams.
May 11, 2019
Wong LP. Achieving dialysis safety: The critical role of higher-functioning teams. Semin Dial.
2019;32(3):266-273. doi:10.1111/sdi.12778.
https://psnet.ahrq.gov/issue/achieving-dialysis-safety-critical-role-higher-functioning-t…
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psnet.ahrq.gov/node/47271/psn-pdf
August 08, 2018 - NAM Action Collaborative on Countering the U.S. Opioid
Epidemic.
August 8, 2018
National Academy of Medicine; Aspen Institute.
https://psnet.ahrq.gov/issue/nam-action-collaborative-countering-us-opioid-epidemic
Despite increased awareness regarding the public health impacts of opioid misuse and overdose in the
Un…
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psnet.ahrq.gov/node/46865/psn-pdf
March 07, 2018 - Chasing the 6-sigma: drawing lessons from the cockpit
culture.
March 7, 2018
Hickey EJ, Halvorsen F, Laussen PC, et al. Chasing the 6-sigma: Drawing lessons from the cockpit culture.
J Thorac Cardiovasc Surg. 2017;155(2). doi:10.1016/j.jtcvs.2017.09.097.
https://psnet.ahrq.gov/issue/chasing-6-sigma-drawing-lessons…
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psnet.ahrq.gov/node/47087/psn-pdf
May 02, 2018 - The Economics of Patient Safety in Primary and
Ambulatory Care: Flying Blind.
May 2, 2018
Slawomirski L, Auraaen A, Klazinga N. Paris, France: Organisation for Economic Co-operation and
Development; 2018.
https://psnet.ahrq.gov/issue/economics-patient-safety-primary-and-ambulatory-care-flying-blind
The global eco…
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psnet.ahrq.gov/node/47294/psn-pdf
November 19, 2018 - 2017 John M. Eisenberg Patient Safety and Quality
Awards.
November 19, 2018
Jt Comm J Qual Patient Saf. 2018;44(7):373-400.
https://psnet.ahrq.gov/issue/2017-john-m-eisenberg-patient-safety-and-quality-awards
The Eisenberg Award honors individuals and organizations who have made unique and sustained
contributions…
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psnet.ahrq.gov/node/47270/psn-pdf
August 08, 2018 - A method to identify pediatric high-risk diagnoses missed
in the emergency department.
August 8, 2018
Sundberg M, Perron CO, Kimia A, et al. A method to identify pediatric high-risk diagnoses missed in the
emergency department. Diagnosis (Berl). 2018;5(2):63-69. doi:10.1515/dx-2018-0005.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/45421/psn-pdf
December 14, 2016 - The medication reconciliation process and classification
of discrepancies: a systematic review.
December 14, 2016
Almanasreh E, Moles R, Chen TF. The medication reconciliation process and classification of
discrepancies: a systematic review. Br J Clin Pharmacol. 2016;82(3):645-658. doi:10.1111/bcp.13017.
https://p…