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  1. psnet.ahrq.gov/issue/medical-error-care-unrepresented-disclosure-and-apology-vulnerable-patient-population
    March 13, 2024 - Commentary Medical error in the care of the unrepresented: disclosure and apology for a vulnerable patient population. Citation Text: Byju AS, Mayo K. Medical error in the care of the unrepresented: disclosure and apology for a vulnerable patient population. J Med Ethics. 2019;45(12):821…
  2. psnet.ahrq.gov/issue/measurement-quality-and-assurance-safety-critically-ill
    March 21, 2012 - Commentary Measurement of quality and assurance of safety in the critically ill. Citation Text: Pronovost P, Sexton B, Pham JC, et al. Measurement of quality and assurance of safety in the critically ill. Clin Chest Med. 2009;30(1):169-79, x. doi:10.1016/j.ccm.2008.09.004. Copy Citat…
  3. psnet.ahrq.gov/issue/reevaluation-diagnosis-adults-physician-diagnosed-asthma
    March 15, 2017 - Study Reevaluation of diagnosis in adults with physician-diagnosed asthma. Citation Text: Aaron SD, Vandemheen KL, FitzGerald M, et al. Reevaluation of Diagnosis in Adults With Physician-Diagnosed Asthma. JAMA. 2017;317(3):269-279. doi:10.1001/jama.2016.19627. Copy Citation Format:…
  4. psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone-overdose
    June 03, 2020 - Newspaper/Magazine Article Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. Citation Text: Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. ISMP Medication Safety Alert! Acute care edition. May 7…
  5. psnet.ahrq.gov/issue/hcup-statistical-brief-313-trends-severe-maternal-morbidity-complications-patient
    December 16, 2009 - Book/Report HCUP Statistical Brief #312. Trends in Severe Maternal Morbidity Complications by Patient Characteristics, 2016-2021. Citation Text: Reid LD. Hcup Statistical Brief #313. Trends In Severe Maternal Morbidity Complications By Patient Characteristics, 2016-2021. Rockville, MD: A…
  6. psnet.ahrq.gov/issue/advancing-medication-safety-establishing-national-action-plan-adverse-drug-event-prevention
    September 29, 2017 - Commentary Advancing medication safety: establishing a National Action Plan for Adverse Drug Event Prevention. Citation Text: Harris Y, Hu DJ, Lee C, et al. Advancing Medication Safety: Establishing a National Action Plan for Adverse Drug Event Prevention. Jt Comm J Qual Patient Saf. 201…
  7. psnet.ahrq.gov/issue/human-cognition-and-dynamics-failure-rescue-lewis-blackman-case
    April 24, 2018 - Commentary Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. Citation Text: Acquaviva K, Haskell H, Johnson J. Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. J Prof Nurs. 2013;29(2):95-101. doi:10.1016/j.profnurs.2012.12.009.…
  8. psnet.ahrq.gov/issue/why-even-good-physicians-do-not-wash-their-hands
    September 21, 2022 - Commentary Why even good physicians do not wash their hands. Citation Text: Redelmeier DA, Shafir E. Why even good physicians do not wash their hands. BMJ Qual Saf. 2015;24(12):744-7. doi:10.1136/bmjqs-2015-004319. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndN…
  9. psnet.ahrq.gov/issue/notes-healing-after-missed-diagnosis
    May 18, 2022 - Commentary Notes on healing after a missed diagnosis. Citation Text: Fleming EA. Notes on healing after a missed diagnosis. JAMA. 2022;328(13):1297-1298. doi:10.1001/jama.2022.15724. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…
  10. psnet.ahrq.gov/issue/time-out-procedure-institutional-ethnography-how-it-conducted-actual-clinical-practice
    November 06, 2015 - Study The 'time-out' procedure: an institutional ethnography of how it is conducted in actual clinical practice. Citation Text: Braaf S, Manias E, Riley R. The 'time-out' procedure: an institutional ethnography of how it is conducted in actual clinical practice. BMJ Qual Saf. 2013;22(8)…
  11. psnet.ahrq.gov/issue/recasting-rca-improved-model-performing-root-cause-analyses
    November 10, 2010 - Commentary ReCASTing the RCA: an improved model for performing root cause analyses. Citation Text: Pham JC, Kim GR, Natterman JP, et al. ReCASTing the RCA: An Improved Model for Performing Root Cause Analyses. American Journal of Medical Quality. 2010;25(3). doi:10.1177/1062860609359533…
  12. psnet.ahrq.gov/issue/hospital-rns-experiences-disruptive-behavior-qualitative-study
    September 09, 2015 - Study Hospital RNs' experiences with disruptive behavior: a qualitative study. Citation Text: Walrath JM, Dang D, Nyberg D. Hospital RNs' experiences with disruptive behavior: a qualitative study. J Nurs Care Qual. 2010;25(2):105-116. doi:10.1097/NCQ.0b013e3181c7b58e. Copy Citation …
  13. psnet.ahrq.gov/issue/towards-safer-better-healthcare-harnessing-natural-properties-complex-sociotechnical-systems
    April 08, 2011 - Commentary Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. Citation Text: Braithwaite J, Runciman WB, Merry AF. Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems. Qual Saf Health …
  14. psnet.ahrq.gov/issue/patient-involvement-patient-safety-qualitative-study-nursing-staff-and-patient-perceptions
    March 02, 2016 - Study Patient involvement in patient safety: a qualitative study of nursing staff and patient perceptions. Citation Text: Bishop A, Macdonald M. Patient Involvement in Patient Safety: A Qualitative Study of Nursing Staff and Patient Perceptions. J Patient Saf. 2017;13(2):82-87. doi:10.10…
  15. psnet.ahrq.gov/issue/e-prescribing-characterisation-patient-safety-hazards-community-pharmacies-using
    January 07, 2015 - Study e-Prescribing: characterisation of patient safety hazards in community pharmacies using a sociotechnical systems approach. Citation Text: Odukoya OK, Chui MA. e-Prescribing: characterisation of patient safety hazards in community pharmacies using a sociotechnical systems approac…
  16. psnet.ahrq.gov/issue/cross-cultural-survey-residents-perceived-barriers-questioningchallenging-authority
    June 15, 2012 - Study A cross-cultural survey of residents' perceived barriers in questioning/challenging authority. Citation Text: Kobayashi H, Pian-Smith M, Sato M, et al. A cross-cultural survey of residents' perceived barriers in questioning/challenging authority. Qual Saf Health Care. 2006;15(4):…
  17. psnet.ahrq.gov/issue/changing-patient-safety-mindset-can-safety-cases-help
    July 14, 2021 - Commentary Changing the patient safety mindset: can safety cases help? Citation Text: Sujan M, Habli I. Changing the patient safety mindset: can safety cases help? BMJ Qual Saf. 2024;33(3):145-148. doi:10.1136/bmjqs-2023-016652. Copy Citation Format: DOI Google Scholar BibT…
  18. psnet.ahrq.gov/issue/err-human-what-happens-when-surgeons-err
    August 04, 2021 - Study To err is human, but what happens when surgeons err? Citation Text: Lin JS, Olutoye OO, Samora JB. To err is human, but what happens when surgeons err? J Pediatr Surg. 2023;58(3):496-502. doi:10.1016/j.jpedsurg.2022.06.019. Copy Citation Format: DOI Google Scholar Bib…
  19. psnet.ahrq.gov/issue/need-organizational-change-patient-safety-initiatives
    May 12, 2010 - Study The need for organizational change in patient safety initiatives. Citation Text: Anderson J, Ramanujam R, Hensel D, et al. The need for organizational change in patient safety initiatives. Int J Med Inform. 2006;75(12):809-17. Copy Citation Format: Google Scholar Pu…
  20. psnet.ahrq.gov/issue/influence-causes-and-contexts-medical-errors-emergency-medicine-residents-responses-their
    April 11, 2011 - Study The influence of the causes and contexts of medical errors on emergency medicine residents' responses to their errors: an exploration. Citation Text: Hobgood C, Hevia A, Tamayo-Sarver JH, et al. The influence of the causes and contexts of medical errors on emergency medicine resi…

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