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psnet.ahrq.gov/node/34094/psn-pdf
September 27, 2017 - Surveillance of medical device-related hazards and
adverse events in hospitalized patients.
September 27, 2017
Samore MH, Evans S, Lassen A, et al. Surveillance of medical device-related hazards and adverse events
in hospitalized patients. JAMA. 2004;291(3):325-34.
https://psnet.ahrq.gov/issue/surveillance-medical…
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psnet.ahrq.gov/node/37814/psn-pdf
April 11, 2011 - Reevaluating the safety profile of pediatrics: a
comparison of computerized adverse drug event
surveillance and voluntary reporting in the pediatric
environment.
April 11, 2011
Ferranti J, Horvath MM, Cozart H, et al. Reevaluating the safety profile of pediatrics: a comparison of
computerized adverse drug event s…
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psnet.ahrq.gov/node/841471/psn-pdf
December 14, 2022 - Cohort study of diagnostic delay in the clinical pathway of
patients with chronic wounds in the primary care setting.
December 14, 2022
Ahmajärvi K, Isoherranen K, Venermo M. Cohort study of diagnostic delay in the clinical pathway of
patients with chronic wounds in the primary care setting. BMJ Open. 2022;12(11):e…
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psnet.ahrq.gov/node/47482/psn-pdf
December 05, 2018 - Examining the effects of an obstetrics interprofessional
programme on reductions to reportable events and their
related costs.
December 5, 2018
Geary M, Ruiter PJA, Yasseen AS. Examining the effects of an obstetrics interprofessional programme on
reductions to reportable events and their related costs. J Interprof…
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psnet.ahrq.gov/node/47251/psn-pdf
July 25, 2018 - Fail-safe patient ID matching remains just out of reach.
July 25, 2018
Arndt RZ. Mod Healthc. July 14, 2018.
https://psnet.ahrq.gov/issue/fail-safe-patient-id-matching-remains-just-out-reach
Similarities in patient names and clinical situations can result in medical errors. Discussing how digital
technologies can …
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psnet.ahrq.gov/node/34103/psn-pdf
February 24, 2011 - Measuring errors and adverse events in health care.
February 24, 2011
Thomas EJ, Petersen LA. Measuring errors and adverse events in health care. J Gen Intern Med.
2003;18(1). doi:10.1046/j.1525-1497.2003.20147.x.
https://psnet.ahrq.gov/issue/measuring-errors-and-adverse-events-health-care
This article discusses t…
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psnet.ahrq.gov/node/856590/psn-pdf
November 29, 2023 - Team experiences of the root cause analysis process
after a sentinel event: a qualitative case study.
November 29, 2023
Liepelt S, Sundal H, Kirchhoff R. Team experiences of the root cause analysis process after a sentinel
event: a qualitative case study. BMC Health Serv Res. 2023;23(1):1224. doi:10.1186/s12913-023…
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psnet.ahrq.gov/node/47591/psn-pdf
January 01, 2021 - Advancing patient safety through the clinical application
of a framework focused on communication.
December 19, 2018
Manojlovich M, Hofer TP, Krein SL. Advancing Patient Safety Through the Clinical Application of a
Framework Focused on Communication. J Patient Saf. 2021;17(8):e732-e737.
doi:10.1097/PTS.00000000000…
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psnet.ahrq.gov/issue/affordable-health-care-floridians-act
January 15, 2025 - Legislation/Regulation
Affordable Health Care for Floridians Act.
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August 27, 2008
Established the patient safety center in the st…
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psnet.ahrq.gov/node/43899/psn-pdf
February 18, 2015 - Development and validation of a taxonomy of adverse
handover events in hospital settings.
February 18, 2015
Andersen HB, Siemsen IMD, Petersen LF, et al. Development and validation of a taxonomy of adverse
handover events in hospital settings. Cognition, Technology & Work. 2014;17(1). doi:10.1007/s10111-014-
0303-…
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psnet.ahrq.gov/node/60743/psn-pdf
July 29, 2020 - The confused and bewildered hospital: adverse event
discovery, pay-for-performance, and big data tools as
halfway technologies.
July 29, 2020
Furrow BR. The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big
data tools as halfway technologies. Am J Law Med. 2020;46(2-3):219-235…
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psnet.ahrq.gov/node/837147/psn-pdf
May 18, 2022 - Patient safety in home care: a multicenter cross-sectional
study about medication errors and medication
management of nurses.
May 18, 2022
Strube?Lahmann S, Müller?Werdan U, Klingelhöfer?Noe J, et al. Patient safety in home care: A multicenter
cross?sectional study about medication errors and medication management…
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psnet.ahrq.gov/node/50432/psn-pdf
September 04, 2019 - Patient Suicide on a Locked Mental Health Unit at the
West Palm Beach VA Medical Center, Florida.
September 4, 2019
Washington, DC: Department of Veterans Affairs, Office of Inspector General. August 22, 2019. Report No.
19-07429-195.
https://psnet.ahrq.gov/issue/patient-suicide-locked-mental-health-unit-west-palm…
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psnet.ahrq.gov/node/46684/psn-pdf
January 24, 2018 - Threats to patient safety in primary care reported by older
people with multimorbidity: baseline findings from a
longitudinal qualitative study and implications for
intervention.
January 24, 2018
Hays R, Daker-White G, Esmail A, et al. Threats to patient safety in primary care reported by older people
with multim…
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psnet.ahrq.gov/node/837025/psn-pdf
May 04, 2022 - Central venous catheter guidewire retention: lessons
from England's never event database.
May 4, 2022
Mariyaselvam MZA, Patel V, Young HE, et al. Central venous catheter guidewire retention: lessons from
England's never event database. J Patient Saf. 2022;18(2):e387-e392.
doi:10.1097/pts.0000000000000826.
https:/…
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psnet.ahrq.gov/node/36314/psn-pdf
June 13, 2011 - Discontinuity of chronic medications in patients
discharged from the intensive care unit.
June 13, 2011
Bell CM, Rahimi-Darabad P, Orner AI. Discontinuity of chronic medications in patients discharged from the
intensive care unit. J Gen Intern Med. 2006;21(9):937-41.
https://psnet.ahrq.gov/issue/discontinuity-chro…
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psnet.ahrq.gov/node/50596/psn-pdf
October 30, 2019 - Encouraging resident adverse event reporting: a
qualitative study of suggestions from the front lines.
October 30, 2019
Szymusiak J, Walk TJ, Benson M, et al. Encouraging Resident Adverse Event Reporting: A Qualitative
Study of Suggestions from the Front Lines. Ped Qual Saf. 2019;4(3):e167.
doi:10.1097/pq9.0000000…
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psnet.ahrq.gov/node/73169/psn-pdf
April 21, 2021 - Application of emergency preparedness principles to a
pharmacy department’s approach to a “black swan”
event: the COVID-19 pandemic.
April 21, 2021
Waldron KM, Schenkat DH, Rao KV, et al. Application of emergency preparedness principles to a
pharmacy department’s approach to a “black swan” event: the COVID-19 pand…
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psnet.ahrq.gov/node/43644/psn-pdf
April 22, 2015 - SIMMEON-Prep study: SIMulation of Medication Errors in
ONcology: prevention of antineoplastic preparation
errors.
April 22, 2015
Sarfati L, Ranchon F, Vantard N, et al. SIMMEON-Prep study: SIMulation of Medication Errors in
ONcology: prevention of antineoplastic preparation errors. J Clin Pharm Ther. 2015;40(1):55…
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psnet.ahrq.gov/node/45230/psn-pdf
July 20, 2016 - Outcomes are worse in US patients undergoing surgery
on weekends compared with weekdays.
July 20, 2016
Glance LG, Osler T, Li Y, et al. Outcomes are Worse in US Patients Undergoing Surgery on Weekends
Compared With Weekdays. Med Care. 2016;54(6):608-15. doi:10.1097/MLR.0000000000000532.
https://psnet.ahrq.gov/issu…