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psnet.ahrq.gov/node/44408/psn-pdf
April 12, 2017 - Enhancing Surgical Performance: A Primer in Non-
technical Skills.
April 12, 2017
Flin R, Youngson GG, Yule S. Boca Raton, FL: CRC Press; 2015. ISBN: 9781482246322.
https://psnet.ahrq.gov/issue/enhancing-surgical-performance-primer-non-technical-skills
Non-technical skill development is gaining attention as a way …
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psnet.ahrq.gov/node/60999/psn-pdf
October 07, 2020 - Global Report on the Epidemiology and Burden of Sepsis:
Current Evidence, Identifying Gaps and Future Directions.
October 7, 2020
Geneva, Switzerland; World Health Organization: September 2020. ISBN 9789240010789.
https://psnet.ahrq.gov/issue/global-report-epidemiology-and-burden-sepsis-current-evidence-identifying…
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psnet.ahrq.gov/node/862610/psn-pdf
February 14, 2024 - Assessing the safety of a new clinical decision support
system for a national helpline.
February 14, 2024
Luckraj N, Strazzari R, Coiera E, et al. Assessing the safety of a new clinical decision support system for a
national helpline. Stud Health Technol Inform. 2024;310:514-518. doi:10.3233/shti231018.
https://ps…
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psnet.ahrq.gov/node/44410/psn-pdf
August 12, 2015 - Workarounds in the workplace: a second look.
August 12, 2015
Seaman JB, Erlen JA. Workarounds in the Workplace: A Second Look. Orthop Nurs. 2015;34(4):235-242.
doi:10.1097/NOR.0000000000000161.
https://psnet.ahrq.gov/issue/workarounds-workplace-second-look
Workarounds are prevalent in health care and create opport…
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psnet.ahrq.gov/node/849138/psn-pdf
May 17, 2023 - Non-accidental Injuries in Infants Attending the
Emergency Department.
May 17, 2023
Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.
https://psnet.ahrq.gov/issue/non-accidental-injuries-infants-attending-emergency-department
Misattribution of child maltreatment injuries can be a serious misdiag…
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psnet.ahrq.gov/node/38345/psn-pdf
February 17, 2009 - Association of communication between hospital-based
physicians and primary care providers with patient
outcomes.
February 17, 2009
Bell CM, Schnipper JL, Auerbach AD, et al. Association of communication between hospital-based
physicians and primary care providers with patient outcomes. J Gen Intern Med. 2009;24(3)…
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psnet.ahrq.gov/node/47462/psn-pdf
October 31, 2018 - Emergency department checklist: an innovation to
improve safety in emergency care.
October 31, 2018
Redfern E, Hoskins R, Gray J, et al. Emergency department checklist: an innovation to improve safety in
emergency care. BMJ Open Qual. 2018;7(3):e000325. doi:10.1136/bmjoq-2018-000325.
https://psnet.ahrq.gov/issue/e…
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psnet.ahrq.gov/node/837667/psn-pdf
July 13, 2022 - Challenges and opportunities of patient safety event
reporting.
July 13, 2022
Gong Y. Challenges and opportunities of patient safety event reporting. Stud Health Technol Inform.
2022;291:133-150. doi:10.3233/shti220014.
https://psnet.ahrq.gov/issue/challenges-and-opportunities-patient-safety-event-reporting
Repor…
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psnet.ahrq.gov/node/73602/psn-pdf
August 18, 2021 - The Child Health PSO at 10 years: an emerging learning
network.
August 18, 2021
Levy FH, Conrad KA, Kemper C, et al. The Child Health PSO at 10 Years: an emerging learning network.
Pediatr Qual Saf. 2021;6(4):e449. doi:10.1097/pq9.0000000000000449.
https://psnet.ahrq.gov/issue/child-health-pso-10-years-emerging-le…
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psnet.ahrq.gov/node/41006/psn-pdf
December 21, 2011 - Failure to notify reportable test results: significance in
medical malpractice.
December 21, 2011
Gale BD, Bissett-Siegel DP, Davidson SJ, et al. Failure to notify reportable test results: significance in
medical malpractice. J Am Coll Radiol. 2011;8(11):776-9. doi:10.1016/j.jacr.2011.06.023.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/44838/psn-pdf
February 10, 2016 - ADVERSE drug events: incidence and risk reduction
across the care continuum.
February 10, 2016
Wanderer JP, Rathmell JP. ADVERSE Drug Events: Incidence & risk reduction across the care continuum.
Anesthesiology. 2016;124(1):A23. doi:10.1097/01.anes.0000473722.20007.03.
https://psnet.ahrq.gov/issue/adverse-drug-eve…
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psnet.ahrq.gov/node/40209/psn-pdf
April 22, 2011 - The efficacy of computer-enabled discharge
communication interventions: a systematic review.
April 22, 2011
Motamedi SM, Posadas-Calleja J, Straus SE, et al. The efficacy of computer-enabled discharge
communication interventions: a systematic review. BMJ Qual Saf. 2011;20(5):403-15.
doi:10.1136/bmjqs.2009.034587.
…
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psnet.ahrq.gov/node/45619/psn-pdf
August 16, 2017 - Checking the lists: a systematic review of electronic
checklist use in health care.
August 16, 2017
Kramer HS, Drews FA. Checking the lists: A systematic review of electronic checklist use in health care. J
Biomed Inform. 2017;71S:S6-S12. doi:10.1016/j.jbi.2016.09.006.
https://psnet.ahrq.gov/issue/checking-lists-s…
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psnet.ahrq.gov/node/867190/psn-pdf
November 20, 2024 - Misdiagnosis is dangerous. Help your doctor get it right.
November 20, 2024
Terry K. Misdiagnosis is dangerous. Help your doctor get it right. WebMD. November 11, 2024;
https://psnet.ahrq.gov/issue/misdiagnosis-dangerous-help-your-doctor-get-it-right
Patients are partners in health care and can inform actions to id…
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psnet.ahrq.gov/node/46628/psn-pdf
December 18, 2017 - Residency evaluations—where is the patient voice?
December 18, 2017
Tummalapalli SL. Residency Evaluations-Where Is the Patient Voice? JAMA Intern Med.
2017;177(12):1722-1723. doi:10.1001/jamainternmed.2017.6029.
https://psnet.ahrq.gov/issue/residency-evaluations-where-patient-voice
Residents rarely receive feedba…
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psnet.ahrq.gov/node/74133/psn-pdf
January 01, 2022 - Predicting avoidable hospital events in Maryland.
December 1, 2021
Henderson M, Han F, Perman C, et al. Predicting avoidable hospital events in Maryland. Health Serv Res.
2022;57(1):192-199. doi:10.1111/1475-6773.13891.
https://psnet.ahrq.gov/issue/predicting-avoidable-hospital-events-maryland
With the goal of imp…
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psnet.ahrq.gov/node/44048/psn-pdf
November 20, 2015 - Clinical handover of the critically ill postoperative patient:
an integrative review.
November 20, 2015
Gardiner TM, Marshall AP, Gillespie BM. Clinical handover of the critically ill postoperative patient: an
integrative review. Aust Crit Care. 2015;28(4):226-34. doi:10.1016/j.aucc.2015.02.001.
https://psnet.ahrq…
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psnet.ahrq.gov/node/36992/psn-pdf
September 14, 2011 - Effect of an anonymous reporting system on near-miss
and harmful medical error reporting in a pediatric
intensive care unit.
September 14, 2011
Grant MJC, Larsen G. Effect of an anonymous reporting system on near-miss and harmful medical error
reporting in a pediatric intensive care unit. J Nurs Care Qual. 2007;22…
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psnet.ahrq.gov/node/35679/psn-pdf
June 28, 2010 - Evaluation of a Web-based education program on
reducing medication dosing error: a multicenter,
randomized controlled trial.
June 28, 2010
Frush K, Hohenhaus S, Luo X, et al. Evaluation of a Web-based education program on reducing
medication dosing error: a multicenter, randomized controlled trial. Pediatr Emerg C…
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psnet.ahrq.gov/node/46330/psn-pdf
September 24, 2017 - Systemic error in radiology.
September 24, 2017
Waite S, Scott JM, Legasto A, et al. Systemic Error in Radiology. AJR Am J Roentgenol. 2017;209(3):629-
639. doi:10.2214/AJR.16.17719.
https://psnet.ahrq.gov/issue/systemic-error-radiology
Radiology interpretation errors can contribute to diagnostic error. This comme…