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psnet.ahrq.gov/node/38994/psn-pdf
March 04, 2011 - Computerized surveillance for adverse drug events in a
pediatric hospital.
March 4, 2011
Kilbridge PM, Noirot LA, Reichley RM, et al. Computerized surveillance for adverse drug events in a
pediatric hospital. J Am Med Inform Assoc. 2009;16(5):607-12. doi:10.1197/jamia.M3167.
https://psnet.ahrq.gov/issue/computeriz…
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psnet.ahrq.gov/node/46210/psn-pdf
July 12, 2017 - Could emotional intelligence make patients safer?
July 12, 2017
Codier E, Codier DD. Could Emotional Intelligence Make Patients Safer? Am J Nurs. 2017;117(7):58-62.
doi:10.1097/01.NAJ.0000520946.39224.db.
https://psnet.ahrq.gov/issue/could-emotional-intelligence-make-patients-safer
Nontechnical skill development i…
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psnet.ahrq.gov/node/73991/psn-pdf
October 20, 2021 - Digital Clinical Safety Strategy
October 20, 2021
NHSX, NHS Digital, NHS England, et al. London, England: Crown Copyright; September 2021.
https://psnet.ahrq.gov/issue/digital-clinical-safety-strategy
Digital clinical technologies hold promise for care improvement while contributing to potential failures due to
th…
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psnet.ahrq.gov/node/60565/psn-pdf
June 03, 2020 - The public has been forgiving. But hospitals got some
things wrong.
June 3, 2020
Ofri D. The public has been forgiving. But hospitals got some things wrong. New York Times. 2020; May
21.
https://psnet.ahrq.gov/issue/public-has-been-forgiving-hospitals-got-some-things-wrong
The complexity of the COVID-19 crisis cr…
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psnet.ahrq.gov/node/40713/psn-pdf
August 24, 2011 - Medication reconciliation: barriers and facilitators from
the perspectives of resident physicians and pharmacists.
August 24, 2011
Boockvar KS, Santos SL, Kushniruk AW, et al. Medication reconciliation: Barriers and facilitators from the
perspectives of resident physicians and pharmacists. J Hosp Med. 2011;6(6). do…
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psnet.ahrq.gov/node/50743/psn-pdf
December 18, 2019 - Design of a safety dashboard for patients.
December 18, 2019
Gibson B, Butler J, Schnock KO, et al. Design of a safety dashboard for patients. Patient Educ Couns.
2019;103(4):741-747. doi:10.1016/j.pec.2019.10.021.
https://psnet.ahrq.gov/issue/design-safety-dashboard-patients
Patients and caregivers should be acti…
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psnet.ahrq.gov/node/45450/psn-pdf
February 13, 2018 - Avoiding Unconscious Bias: a Guide for Surgeons.
February 13, 2018
London, UK: Royal College of Surgeons of England; 2016.
https://psnet.ahrq.gov/issue/avoiding-unconscious-bias-guide-surgeons
Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides
information for sur…
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psnet.ahrq.gov/node/46634/psn-pdf
November 22, 2017 - Ambulatory Care Patient Safety 2017–2018.
November 22, 2017
National Quality Forum; NQF.
https://psnet.ahrq.gov/issue/ambulatory-care-patient-safety-2017-2018
Patient safety in ambulatory care is emerging as a focus of research, regulation, and measurement efforts.
This website provides information and resources r…
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psnet.ahrq.gov/node/48136/psn-pdf
August 07, 2019 - Safe Practices for Drug Allergies—Using CDS and Health
IT.
August 7, 2019
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2019.
https://psnet.ahrq.gov/issue/safe-practices-drug-allergies-using-cds-and-health-it
Inconsistent checking for and consideration of drug allergy alerts can d…
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psnet.ahrq.gov/node/46452/psn-pdf
November 15, 2017 - Quality Improvement.
November 15, 2017
Gupta M, Kaplan HC, eds. Clin Perinatol. 2017;44(3):469-728.
https://psnet.ahrq.gov/issue/quality-improvement
Improvement efforts in health care focus on quality and patient safety. Articles in this special issue explore
the complexities of providing effective perinatal–neona…
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psnet.ahrq.gov/node/836717/psn-pdf
March 09, 2022 - The problem with…using stories as a source of evidence
and learning.
March 9, 2022
Iedema R. The problem with … using stories as a source of evidence and learning. BMJ Qual Saf.
2022;31(3):234-237. doi:10.1136/bmjqs-2021-014221.
https://psnet.ahrq.gov/issue/problem-withusing-stories-source-evidence-and-learning
P…
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psnet.ahrq.gov/node/43790/psn-pdf
October 23, 2023 - Complaints to the Parliamentary and Health Service
Ombudsman.
October 23, 2023
Manchester, UK: Parliamentary and Health Service Ombudsman.
https://psnet.ahrq.gov/issue/complaints-about-acute-trusts-2016-2017
The National Health Service broadly reports the results of system-level analyses and investigations into
t…
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psnet.ahrq.gov/node/36085/psn-pdf
September 28, 2010 - VA Health Care: Selected Credentialing Requirements at
Seven Medical Facilities Met, but an Aspect of Privileging
Process Needs Improvement.
September 28, 2010
Washington, DC: Government Accountability Office; May 2006. Report no GAO-06-648.
https://psnet.ahrq.gov/issue/va-health-care-selected-credentialing-requir…
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psnet.ahrq.gov/node/39098/psn-pdf
November 11, 2009 - Building team and technical competency for obstetric
emergencies: the mobile obstetric emergencies simulator
(MOES) system.
November 11, 2009
Deering S, Rosen MA, Salas E, et al. Building team and technical competency for obstetric emergencies:
the mobile obstetric emergencies simulator (MOES) system. Simul Health…
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psnet.ahrq.gov/node/37857/psn-pdf
May 26, 2011 - The impact of computerized physician medication order
entry in hospitalized patients—a systematic review.
May 26, 2011
Eslami S, de Keizer NF, Abu-Hanna A. The impact of computerized physician medication order entry in
hospitalized patients--a systematic review. Int J Med Inform. 2008;77(6):365-76.
https://psnet.a…
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psnet.ahrq.gov/node/865588/psn-pdf
April 17, 2024 - Inattentional blindness in medicine.
April 17, 2024
Hults CM, Ding Y, Xie GG, et al. Inattentional blindness in medicine. Cogn Res Princ Implic. 2024;9(1):18.
doi:10.1186/s41235-024-00537-x.
https://psnet.ahrq.gov/issue/inattentional-blindness-medicine
Inattentional blindness occurs when a person is focused so int…
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psnet.ahrq.gov/node/43477/psn-pdf
May 19, 2015 - Adverse events in healthcare: learning from mistakes.
May 19, 2015
Rafter N, Hickey A, Condell S, et al. Adverse events in healthcare: learning from mistakes. QJM.
2015;108(4):273-7. doi:10.1093/qjmed/hcu145.
https://psnet.ahrq.gov/issue/adverse-events-healthcare-learning-mistakes
This review discusses chart revie…
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psnet.ahrq.gov/node/854266/psn-pdf
October 04, 2023 - Smart Healthcare Safety.
October 4, 2023
Plymouth Meeting PA, ECRI. 2019-2023.
https://psnet.ahrq.gov/issue/smart-healthcare-safety
A wide variety of considerations must converge to inform an understanding of system vulnerabilities and
the application of strategies to address them. This series of webinars covers a…
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psnet.ahrq.gov/node/866359/psn-pdf
June 01, 2022 - Diagnostic Safety Toolkit.
June 1, 2022
Diagnostic Safety Toolkit.
https://psnet.ahrq.gov/issue/diagnostic-safety-toolkit-0
Effective communication is critical as patients shift from one level of care to another as their diagnosis
evolves. This toolkit is designed to help academic medical centers initiate conversa…
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psnet.ahrq.gov/node/42902/psn-pdf
January 29, 2014 - Improving Patient Safety Through Teamwork and Team
Training.
January 29, 2014
Salas E, Frush K, eds. Oxford, UK: Oxford University Press; 2013. ISBN: 9780195399097.
https://psnet.ahrq.gov/issue/improving-patient-safety-through-teamwork-and-team-training
Health care has been recently been directed toward focusing o…