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psnet.ahrq.gov/node/837500/psn-pdf
June 22, 2022 - Analysis of hospital-level readmission rates and variation
in adverse events among patients with pneumonia in the
United States.
June 22, 2022
Wang Y, Eldridge N, Metersky ML, et al. Analysis of hospital-level readmission rates and variation in
adverse events among patients with pneumonia in the United States. JAM…
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psnet.ahrq.gov/node/837589/psn-pdf
June 29, 2022 - Monitoring preventable adverse events and near misses:
number and type identified differ depending on method
used.
June 29, 2022
Isaksson S, Schwarz A, Rusner M, et al. Monitoring preventable adverse events and near misses: number
and type identified differ depending on method used. J Patient Saf. 2022;18(4):325-3…
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psnet.ahrq.gov/node/46897/psn-pdf
October 13, 2018 - An assessment of the impact of just culture on quality
and safety in US hospitals.
October 13, 2018
Edwards MT. An Assessment of the Impact of Just Culture on Quality and Safety in US Hospitals. Am J
Med Qual. 2018;33(5):502-508. doi:10.1177/1062860618768057.
https://psnet.ahrq.gov/issue/assessment-impact-just-cul…
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psnet.ahrq.gov/node/73315/psn-pdf
May 26, 2021 - What contributes to diagnostic error or delay? A
qualitative exploration across diverse acute care settings
in the United States.
May 26, 2021
Barwise A, Leppin A, Dong Y, et al. What contributes to diagnostic error or delay? A qualitative exploration
across diverse acute care settings in the United States. J Pati…
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psnet.ahrq.gov/node/73131/psn-pdf
April 14, 2021 - Identification of common themes from never events data
published by NHS England.
April 14, 2021
Omar I, Graham Y, Singhal R, et al. Identification of common themes from never events data published by
NHS England. World J Surg. 2021;45(3):697-704. doi:10.1007/s00268-020-05867-7.
https://psnet.ahrq.gov/issue/identif…
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psnet.ahrq.gov/node/35486/psn-pdf
December 06, 2011 - The poor state of health care quality in the U.S.: is
malpractice liability part of the problem or part of the
solution?
December 6, 2011
Hyman DA, Silver C. The poor state of health care quality in the U.S.: is malpractice liability part of the
problem or part of the solution? Cornell Law Rev. 2005;90(4):893-993.…
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psnet.ahrq.gov/node/854991/psn-pdf
November 01, 2023 - Assessing biases in medical decisions via clinician and
AI chatbot responses to patient vignettes.
November 1, 2023
Kim J, Cai ZR, Chen ML, et al. Assessing biases in medical decisions via clinician and AI chatbot
responses to patient vignettes. JAMA Netw Open. 2023;6(10):e2338050.
doi:10.1001/jamanetworkopen.2023…
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psnet.ahrq.gov/node/850917/psn-pdf
June 21, 2023 - Improving safety outcomes through medical error
reduction via virtual reality-based clinical skills training.
June 21, 2023
Kennedy GAL, Pedram S, Sanzone S. Improving safety outcomes through medical error reduction via
virtual reality-based clinical skills training. Safety Sci. 2023;165:106200. doi:10.1016/j.ssci.…
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psnet.ahrq.gov/node/867044/psn-pdf
October 30, 2024 - "Near miss": a mixed-methods analysis of medical
student assignments in patient safety.
October 30, 2024
Plugge T, Breviu A, Lappé K, et al. "Near miss": a mixed-methods analysis of medical student assignments
in patient safety. Am J Med Qual. 2024;39(4):168-173. doi:10.1097/jmq.0000000000000196.
https://psnet.ahr…
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psnet.ahrq.gov/node/839821/psn-pdf
November 09, 2022 - Cognitive biases encountered by physicians in the
emergency room.
November 9, 2022
Kunitomo K, Harada T, Watari T. Cognitive biases encountered by physicians in the emergency room.
BMC Emerg Med. 2022;22(1):148. doi:10.1186/s12873-022-00708-3.
https://psnet.ahrq.gov/issue/cognitive-biases-encountered-physicians-em…
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psnet.ahrq.gov/node/37040/psn-pdf
April 11, 2011 - The host hospital 24-hour underreferral rate: an
automated measure of call-center safety.
April 11, 2011
Hirsh DA, Simon HK, Massey R, et al. The host hospital 24-hour underreferral rate: an automated measure
of call-center safety. Pediatrics. 2007;119(6):1139-1144.
https://psnet.ahrq.gov/issue/host-hospital-24-ho…
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psnet.ahrq.gov/node/838077/psn-pdf
September 14, 2022 - Healthcare-associated adverse events in alternate level of
care patients awaiting long-term care in hospital.
September 14, 2022
Lim Fat GJ, Gopaul A, Pananos AD, et al. Healthcare-associated adverse events in alternate level of care
patients awaiting long-term care in hospital. Geriatrics (Basel). 2022;7(4):81.
d…
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psnet.ahrq.gov/node/847048/psn-pdf
April 05, 2023 - Comparison of health care worker satisfaction before vs
after implementation of a communication and optimal
resolution program in acute care hospitals.
April 5, 2023
Friedson AI, Humphreys A, LeCraw F, et al. Comparison of health care worker satisfaction before vs after
implementation of a communication and optima…
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psnet.ahrq.gov/node/837768/psn-pdf
August 03, 2022 - Comparison of a voluntary safety reporting system to a
global trigger tool for identifying adverse events in an
oncology population.
August 3, 2022
Samal L, Khasnabish S, Foskett C, et al. Comparison of a voluntary safety reporting system to a global
trigger tool for identifying adverse events in an oncology popul…
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psnet.ahrq.gov/node/50862/psn-pdf
February 05, 2020 - Assessment of nursing home reporting of major injury
falls for quality measurement on Nursing Home Compare.
February 5, 2020
Sanghavi P, Pan S, Caudry D. Assessment of nursing home reporting of major injury falls for quality
measurement on nursing home compare. Health Serv Res. 2020;55(2):201-210. doi:10.1111/1475-…
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psnet.ahrq.gov/node/40513/psn-pdf
June 08, 2011 - "Sign right here and you're good to go": a content
analysis of audiotaped emergency department discharge
instructions.
June 8, 2011
Vashi A, Rhodes K. "Sign right here and you're good to go": a content analysis of audiotaped emergency
department discharge instructions. Ann Emerg Med. 2011;57(4):315-322.e1.
doi:10…
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psnet.ahrq.gov/node/74728/psn-pdf
February 02, 2022 - Technology-based closed-loop tracking for improving
communication and follow-up of pathology results.
February 2, 2022
Rajan SS, Baldwin J, Giardina TD, et al. Technology-based closed-loop tracking for improving
communication and follow-up of pathology results. J Patient Saf. 2022;18(1):e262-e266.
doi:10.1097/pts.…
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psnet.ahrq.gov/node/73608/psn-pdf
January 01, 2022 - Pharmacist-led intervention on the reduction of
inappropriate medication use in patients with heart
failure: a systematic review of randomized trials and non-
randomized intervention studies.
August 18, 2021
Hernández-Prats C, López-Pintor E, Lumbreras B. Pharmacist-led intervention on the reduction of
inappropri…
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psnet.ahrq.gov/node/72579/psn-pdf
January 01, 2021 - Registration errors among patients receiving blood
transfusions: a national analysis from 2008 to 2017.
December 16, 2020
Vijenthira S, Armali C, Downie H, et al. Registration errors among patients receiving blood transfusions: a
national analysis from 2008 to 2017. Vox Sang. 2021;116(2):225-233. doi:10.1111/vox.13…
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psnet.ahrq.gov/node/41352/psn-pdf
May 09, 2012 - ASHP national survey of pharmacy practice in hospital
settings: dispensing and administration—2011.
May 9, 2012
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital
settings: Dispensing and administration—2011. American Journal of Health-System Pharmacy. 2012;69(9).
doi…