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psnet.ahrq.gov/node/45060/psn-pdf
January 01, 2017 - Patient safety during sedation by anesthesia
professionals during routine upper endoscopy and
colonoscopy: an analysis of 1.38 million procedures.
December 30, 2016
Vargo JJ, Niklewski PJ, Williams L, et al. Patient safety during sedation by anesthesia professionals
during routine upper endoscopy and colonoscopy: …
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psnet.ahrq.gov/node/35210/psn-pdf
June 24, 2009 - Hospitalwide adverse drug events before and after
limiting weekly work hours of medical residents to 80.
June 24, 2009
Mycyk MB, McDaniel MR, Fotis MA, et al. Hospitalwide adverse drug events before and after limiting
weekly work hours of medical residents to 80. Am J Health Syst Pharm. 2005;62(15):1592-5.
https:/…
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psnet.ahrq.gov/node/47565/psn-pdf
April 27, 2019 - Unintentionally retained foreign objects: a descriptive
study of 308 sentinel events and contributing factors.
April 27, 2019
Steelman VM, Shaw C, Shine L, et al. Unintentionally Retained Foreign Objects: A Descriptive Study of
308 Sentinel Events and Contributing Factors. Jt Comm J Qual Patient Saf. 2019;45(4):249…
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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/44450/psn-pdf
November 23, 2016 - The wisdom of patients and families: ignore it at our peril.
November 23, 2016
Donaldson LJ. The wisdom of patients and families: ignore it at our peril. BMJ Qual Saf. 2015;24(10):603-
604. doi:10.1136/bmjqs-2015-004573.
https://psnet.ahrq.gov/issue/wisdom-patients-and-families-ignore-it-our-peril
Narrative elemen…
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psnet.ahrq.gov/node/60019/psn-pdf
March 04, 2020 - Chronic pain diagnoses and opioid dispensings among
insured individuals with serious mental illness.
March 4, 2020
Owen-Smith A, Stewart C, Sesay MM, et al. Chronic pain diagnoses and opioid dispensings among insured
individuals with serious mental illness. BMC Psych. 2020;20(1):40. doi:10.1186/s12888-020-2456-1.
…
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psnet.ahrq.gov/node/73439/psn-pdf
June 30, 2021 - Nurses as 'second victims' to their patients' suicidal
attempts: a mixed-method study.
June 30, 2021
Amit Aharon A, Fariba M, Shoshana F, et al. Nurses as ‘second victims’ to their patients’ suicidal attempts:
a mixed?method study. J Clin Nurs. 2021;30(21-22):3290-3300. doi:10.1111/jocn.15839.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/48105/psn-pdf
July 10, 2019 - Teaching medical students to recognise and report
errors.
July 10, 2019
Mohsin SU, Ibrahim Y, Levine D. Teaching medical students to recognise and report errors. BMJ Open
Qual. 2019;8(2):e000558. doi:10.1136/bmjoq-2018-000558.
https://psnet.ahrq.gov/issue/teaching-medical-students-recognise-and-report-errors
This…
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psnet.ahrq.gov/node/43780/psn-pdf
September 09, 2015 - Rapid response systems and collective (in)competence:
an exploratory analysis of intraprofessional and
interprofessional activation factors.
September 9, 2015
Kitto S, Marshall SD, McMillan SE, et al. Rapid response systems and collective (in)competence: An
exploratory analysis of intraprofessional and interprofes…
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psnet.ahrq.gov/node/35542/psn-pdf
March 29, 2010 - The costs associated with adverse drug events among
older adults in the ambulatory setting.
March 29, 2010
Field T, Gilman BH, Subramanian S, et al. The costs associated with adverse drug events among older
adults in the ambulatory setting. Med Care. 2005;43(12):1171-1176.
https://psnet.ahrq.gov/issue/costs-associ…
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psnet.ahrq.gov/node/46683/psn-pdf
February 14, 2018 - Changing experience of adverse medical events in the
National Health Service: comparison of two population
surveys in 2001 and 2013.
February 14, 2018
Gray AM, Fenn P, Rickman N, et al. Changing experience of adverse medical events in the National Health
Service: Comparison of two population surveys in 2001 and 20…
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psnet.ahrq.gov/node/42833/psn-pdf
January 08, 2014 - Effects of a team-based assessment and intervention on
patient safety culture in general practice: an open
randomised controlled trial.
January 8, 2014
Hoffmann B, Müller V, Rochon J, et al. Effects of a team-based assessment and intervention on patient
safety culture in general practice: an open randomised contro…
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psnet.ahrq.gov/node/44120/psn-pdf
November 06, 2015 - Designing highly reliable adverse-event detection
systems to predict subsequent claims.
November 6, 2015
Helmchen LA, Burke ME, Wojtusiak J. Designing highly reliable adverse-event detection systems to predict
subsequent claims. J Healthc Risk Manag. 2015;34(4):7-17. doi:10.1002/jhrm.21167.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/41954/psn-pdf
November 26, 2014 - Decoding laboratory test names: a major challenge to
appropriate patient care.
November 26, 2014
Passiment E, Meisel JL, Fontanesi J, et al. Decoding laboratory test names: a major challenge to
appropriate patient care. J Gen Intern Med. 2013;28(3):453-8. doi:10.1007/s11606-012-2253-8.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/74182/psn-pdf
December 15, 2021 - Honesty and transparency, indispensable to the clinical
mission--Parts I-III.
December 15, 2021
Brenner MJ, Boothman RC, Rushton CH, et al. Honesty and Transparency, Indispensable to the Clinical
Mission—Parts I - III. Otolaryngol Clin North Am. 2021;55(1):43-103. doi:10.1016/j.otc.2021.07.016.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/844794/psn-pdf
January 01, 2020 - Hospital image repair strategies, organizational apology,
and medical errors: an analysis of the CoxHealth brain
over-radiation case.
September 18, 2019
Carmack HJ. Hospital Image Repair Strategies, Organizational Apology, and Medical Errors: An Analysis of
the CoxHealth Brain Over-Radiation Case. Health Comm. 202…
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psnet.ahrq.gov/node/74091/psn-pdf
November 17, 2021 - Patients went into the hospital for care. After testing
positive there for Covid, some never came out.
November 17, 2021
Jewett C. Kaiser Health News. November 4, 2021.
https://psnet.ahrq.gov/issue/patients-went-hospital-care-after-testing-positive-there-covid-some-never-
came-out
Nosocomial infection is a primar…
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psnet.ahrq.gov/node/72477/psn-pdf
January 01, 2021 - Inpatient patient safety events in vulnerable populations:
a retrospective cohort study.
November 18, 2020
Schulson LB, Novack V, Folcarelli PH, et al. Inpatient patient safety events in vulnerable populations: a
retrospective cohort study. BMJ Qual Saf. 2021;30(5):372-379. doi:10.1136/bmjqs-2020-011920.
https://p…
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psnet.ahrq.gov/node/837598/psn-pdf
June 29, 2022 - Visitor behaviors can influence the risk of patient harm:
an analysis of patient safety reports from 92 hospitals.
June 29, 2022
Sanchez C, Taylor M, Jones RM. Visitor behaviors can influence the risk of patient harm: an analysis of
patient safety reports from 92 hospitals. Patient Safety. 2022;4(2):70-79. doi:10.3…
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psnet.ahrq.gov/node/43387/psn-pdf
August 20, 2014 - The occurrence of adverse events potentially attributable
to nursing care in medical units: cross sectional record
review.
August 20, 2014
D'Amour D, Dubois C-A, Tchouaket E, et al. The occurrence of adverse events potentially attributable to
nursing care in medical units: cross sectional record review. Int J Nurs…