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psnet.ahrq.gov/node/35650/psn-pdf
June 25, 2010 - Am I safe here? Improving patients' perceptions of safety
in hospitals.
June 25, 2010
Wolosin RJ, Vercler L, Matthews JL. Am I safe here?: improving patients' perceptions of safety in hospitals.
J Nurs Care Qual. 2006;21(1):30-40.
https://psnet.ahrq.gov/issue/am-i-safe-here-improving-patients-perceptions-safety-ho…
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psnet.ahrq.gov/node/37245/psn-pdf
December 16, 2011 - Is the availability of hospital IT applications associated
with a hospital's risk adjusted incidence rate for patient
safety indicators: results from 66 Georgia hospitals.
December 16, 2011
Culler SD, Hawley JN, Naylor V, et al. Is the availability of hospital IT applications associated with a
hospital's risk adju…
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psnet.ahrq.gov/node/40731/psn-pdf
December 31, 2014 - Making electronic prescribing alerts more effective:
scenario-based experimental study in junior doctors.
December 31, 2014
Scott GPT, Shah P, Wyatt JC, et al. Making electronic prescribing alerts more effective: scenario-based
experimental study in junior doctors. J Am Med Inform Assoc. 2011;18(6):789-98. doi:10.1…
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psnet.ahrq.gov/node/60040/psn-pdf
March 11, 2020 - Shifting the Mindset: A Closer Look at Hospital
Complaints.
March 11, 2020
Newcastle upon Tyne, UK: Healthwatch; January 2020.
https://psnet.ahrq.gov/issue/shifting-mindset-closer-look-hospital-complaints
Organizations need to do more than report and collect complaint data to realize improvements based on
what is…
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psnet.ahrq.gov/node/47464/psn-pdf
October 17, 2018 - How to prevent the top 4 medication errors.
October 17, 2018
Sederstrom J. Drug Topics. September 17, 2018.
https://psnet.ahrq.gov/issue/how-prevent-top-4-medication-errors
Medication errors continue to be a worldwide patient safety challenge that requires both systems and
individual practice strategies for improv…
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psnet.ahrq.gov/node/37621/psn-pdf
March 19, 2008 - An effort to improve electronic health record medication
list accuracy between visits: patients' and physicians'
response.
March 19, 2008
Staroselsky M, Volk LA, Tsurikova R, et al. An effort to improve electronic health record medication list
accuracy between visits: patients' and physicians' response. Int J Med …
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psnet.ahrq.gov/node/40545/psn-pdf
June 22, 2011 - Using ORA to explore the relationship of nursing unit
communication to patient safety and quality outcomes.
June 22, 2011
Effken JA, Carley KM, Gephart SM, et al. Using ORA to explore the relationship of nursing unit
communication to patient safety and quality outcomes. Int J Med Inform. 2011;80(7):507-17.
doi:10.…
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psnet.ahrq.gov/node/47961/psn-pdf
January 01, 2021 - Patient and physician experience with interhospital
transfer: a qualitative study.
June 2, 2019
Mueller SK, Shannon E, Dalal A, et al. Patient and Physician Experience with Interhospital Transfer: A
Qualitative Study. J Patient Saf. 2021;17(8):e752-e757. doi:10.1097/PTS.0000000000000501.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/43772/psn-pdf
June 24, 2019 - Betsy Lehman Center for Patient Safety.
June 24, 2019
501 Boylston Street, 5th Floor, Boston, MA, 02116 info@BetsyLehmanCenterMA.gov
https://psnet.ahrq.gov/issue/betsy-lehman-center-patient-safety
The Betsy Lehman Center is a nonregulatory Massachusetts state agency named for Betsy Lehman, the
Boston Globe columni…
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psnet.ahrq.gov/node/46881/psn-pdf
March 28, 2018 - Designing for Safety in the ICU.
March 28, 2018
Hamilton DK, ed. Crit Care Nurs Q. 2018;41(1):1-92.
https://psnet.ahrq.gov/issue/designing-safety-icu
Systems and space design are important considerations for safe care delivery. This special issue explores
how the built environment can affect safety in intensive ca…
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psnet.ahrq.gov/node/46384/psn-pdf
November 14, 2018 - Peggy Lillis Foundation.
November 14, 2018
266 12th Street #6, Brooklyn, NY 11215.
https://psnet.ahrq.gov/issue/peggy-lillis-foundation
Clostridium difficile infections are considered a serious hospital-acquired infection. This grassroots
foundation employs educational, policy, and advocacy strategies aimed at red…
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psnet.ahrq.gov/node/36838/psn-pdf
April 19, 2011 - A very public failure: lessons for quality improvement in
healthcare organisations from the Bristol Royal Infirmary.
April 19, 2011
Walshe K, Offen N. A very public failure: lessons for quality improvement in healthcare organisations from
the Bristol Royal Infirmary. Qual Health Care. 2001;10(4):250-6.
https://psn…
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psnet.ahrq.gov/node/40478/psn-pdf
June 13, 2011 - Evaluating the medication process in the context of CPOE
use: the significance of working around the system.
June 13, 2011
Niazkhani Z, Pirnejad H, van der Sijs H, et al. Evaluating the medication process in the context of CPOE
use: the significance of working around the system. Int J Med Inform. 2011;80(7):490-506…
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psnet.ahrq.gov/node/45160/psn-pdf
May 18, 2016 - Clues to better health care from old malpractice lawsuits.
May 18, 2016
Landro L.
https://psnet.ahrq.gov/issue/clues-better-health-care-old-malpractice-lawsuits
Closed claims have been considered a source for adverse event data for years, and recently such data has
been utilized to inform safety improvement work. …
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psnet.ahrq.gov/node/44141/psn-pdf
November 06, 2015 - Failures in communication through documents and
documentation across the perioperative pathway.
November 6, 2015
Braaf S, Riley R, Manias E. Failures in communication through documents and documentation across the
perioperative pathway. J Clin Nurs. 2015;24(13-14):1874-1884. doi:10.1111/jocn.12809.
https://psnet.a…
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psnet.ahrq.gov/node/43061/psn-pdf
September 01, 2016 - Appropriateness of commercially available and partially
customized medication dosing alerts among pediatric
patients.
September 1, 2016
Stultz JS, Nahata MC. Appropriateness of commercially available and partially customized medication
dosing alerts among pediatric patients. J Am Med Inform Assoc. 2014;21(e1):e35-…
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psnet.ahrq.gov/node/73638/psn-pdf
August 25, 2021 - The pain was unbearable. So why did doctors turn her
away?
August 25, 2021
Szalavitz M. Wired Magazine. August 11, 2021.
https://psnet.ahrq.gov/issue/pain-was-unbearable-so-why-did-doctors-turn-her-away
The opioid epidemic has contributed to uncertainties for pain management patients that result in harm…
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psnet.ahrq.gov/node/36895/psn-pdf
March 10, 2011 - A systematic review of the performance characteristics of
clinical event monitor signals used to detect adverse drug
events in the hospital setting.
March 10, 2011
Handler S, Altman RL, Perera S, et al. A systematic review of the performance characteristics of clinical
event monitor signals used to detect adverse …
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psnet.ahrq.gov/node/844779/psn-pdf
September 11, 2019 - Leveraging patient safety research: efforts made fifteen
years since To Err Is Human.
September 11, 2019
Liang C, Miao Q, Kang H, et al. Leveraging Patient Safety Research: Efforts Made Fifteen Years Since To
Err Is Human. Stud Health Technol Inform. 2019;264:983-987. doi:10.3233/SHTI190371.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/837038/psn-pdf
May 04, 2022 - Mind the Implementation Gap. The Persistence of
Avoidable Harm in the NHS.
May 4, 2022
London UK: Patient Safety Learning: 2022.
https://psnet.ahrq.gov/issue/mind-implementation-gap-persistence-avoidable-harm-nhs
Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financi…