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psnet.ahrq.gov/node/47802/psn-pdf
March 04, 2019 - The path to diagnostic excellence includes feedback to
calibrate how clinicians think.
March 4, 2019
Meyer AND, Singh H. The Path to Diagnostic Excellence Includes Feedback to Calibrate How Clinicians
Think. JAMA. 2019;321(8):737-738. doi:10.1001/jama.2019.0113.
https://psnet.ahrq.gov/issue/path-diagnostic-excelle…
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psnet.ahrq.gov/node/47808/psn-pdf
May 15, 2019 - Virtual patients designed for training against medical
error: exploring the impact of decision-making on learner
motivation.
May 15, 2019
Woodham LA, Round J, Stenfors T, et al. Virtual patients designed for training against medical error:
Exploring the impact of decision-making on learner motivation. PLoS One. 20…
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psnet.ahrq.gov/node/34662/psn-pdf
December 24, 2008 - User's manual for the IOM's 'Quality Chasm' report.
December 24, 2008
Berwick DM. A user's manual for the IOM's 'Quality Chasm' report. Health Aff (Millwood). 2002;21(3):80-90.
https://psnet.ahrq.gov/issue/users-manual-ioms-quality-chasm-report
Fifteen months after releasing its report on patient safety (To Err Is …
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psnet.ahrq.gov/node/74102/psn-pdf
January 01, 2022 - Workforce planning and safe workload in sterile
compounding hospital pharmacy services.
November 24, 2021
Chaker A, Omair I, Mohamed WH, et al. Workforce planning and safe workload in sterile compounding
hospital pharmacy services. Am J Health Syst Pharm. 2022;79(3):187–192. doi:10.1093/ajhp/zxab379.
https://psnet…
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psnet.ahrq.gov/node/35159/psn-pdf
January 02, 2017 - Medication reconciliation in acute care: ensuring an
accurate drug regimen on admission and discharge.
January 2, 2017
Rodehaver C, Fearing D. Medication reconciliation in acute care: ensuring an accurate drug regimen on
admission and discharge. Jt Comm J Qual Patient Saf. 2005;31(7):406-13.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/47068/psn-pdf
June 25, 2018 - The need for closed-loop systems for management of
abnormal test results.
June 25, 2018
Zuccotti G, Samal L, Maloney FL, et al. The Need for Closed-Loop Systems for Management of Abnormal
Test Results. Ann Intern Med. 2018;168(11):820-821. doi:10.7326/M17-2425.
https://psnet.ahrq.gov/issue/need-closed-loop-systems…
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psnet.ahrq.gov/node/838193/psn-pdf
September 28, 2022 - Economics of Medication Safety. Improving Medication
Safety Through Collective, Real-time Learning.
September 28, 2022
de Bienassis K, Esmail L, Lopert R, Klazinga N for the Organisation for Economic Co-operation and
Development. Paris, France: OECD Publishing; 2022. OECD Health Working Papers, No. 147.
…
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psnet.ahrq.gov/node/47586/psn-pdf
March 20, 2019 - Wrong-patient blood transfusion error: leveraging
technology to overcome human error in intraoperative
blood component administration.
March 20, 2019
Hensley NB, Koch CG, Pronovost P, et al. Wrong-Patient Blood Transfusion Error: Leveraging Technology
to Overcome Human Error in Intraoperative Blood Component Admin…
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psnet.ahrq.gov/node/73125/psn-pdf
April 07, 2021 - Black Patients are More Likely Than White Patients to be
in Hospitals with Worse Patient Safety Conditions.
April 7, 2021
Gangopadhyaya A. Washington DC: Urban Institute; March 29, 2021.
https://psnet.ahrq.gov/issue/black-patients-are-more-likely-white-patients-be-hospitals-worse-patient-
safety-conditions
Racial…
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psnet.ahrq.gov/node/39600/psn-pdf
June 16, 2010 - Developing a patient safety surveillance system to
identify adverse events in the intensive care unit.
June 16, 2010
Stockwell DC, Kane-Gill SL. Developing a patient safety surveillance system to identify adverse events in
the intensive care unit. Crit Care Med. 2010;38(6 Suppl):S117-25. doi:10.1097/CCM.0b013e3181d…
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psnet.ahrq.gov/node/74003/psn-pdf
October 27, 2021 - Test-retest reliability of an experienced Global Trigger
Tool review team.
October 27, 2021
Bjørn B, Anhøj J, Østergaard M, et al. Test-retest reliability of an experienced Global Trigger Tool review
team. J Patient Saf. 2021;17(7):e593-e598. doi:10.1097/pts.0000000000000433.
https://psnet.ahrq.gov/issue/test-rete…
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psnet.ahrq.gov/node/35909/psn-pdf
October 07, 2008 - Committed to Safety: Ten Case Studies on Reducing
Harm to Patients.
October 7, 2008
McCarthy D, Blumenthal D. New York, NY: Commonwealth Fund; 2006.
https://psnet.ahrq.gov/issue/committed-safety-ten-case-studies-reducing-harm-patients
This report presents ten case studies to illustrate interventions that address p…
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psnet.ahrq.gov/node/35365/psn-pdf
February 17, 2011 - Accidental deaths, saved lives, and improved quality.
February 17, 2011
Brennan TA, Gawande AA, Thomas EJ, et al. Accidental Deaths, Saved Lives, and Improved Quality. New
England Journal of Medicine. 2005;353(13). doi:10.1056/nejmsb051157.
https://psnet.ahrq.gov/issue/accidental-deaths-saved-lives-and-improved-qua…
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psnet.ahrq.gov/node/34667/psn-pdf
January 17, 2018 - Lessons from the Denver medication error/criminal
negligence case: look beyond blaming individuals.
January 17, 2018
Smetzer JL, Cohen MR. Hosp Pharm. 1998;33(6):640-642,645-646,654-657.
https://psnet.ahrq.gov/issue/lessons-denver-medication-errorcriminal-negligence-case-look-beyond-
blaming-individuals
In Octobe…
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psnet.ahrq.gov/node/45766/psn-pdf
February 08, 2017 - Prescription Drug Monitoring Programs: Evidence-based
Practices to Optimize Prescriber Use.
February 8, 2017
Philadelphia, PA: Pew Charitable Trusts and Institute for Behavioral Health, Heller School for Social Policy
and Management at Brandeis University; 2016.
https://psnet.ahrq.gov/issue/prescription-drug-monit…
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psnet.ahrq.gov/node/43580/psn-pdf
October 01, 2014 - Reducing medication errors in critical care: a multimodal
approach.
October 1, 2014
Kruer RM, Jarrell AS, Latif A. Reducing medication errors in critical care: a multimodal approach. Clin
Pharmacol. 2014;6:117-26. doi:10.2147/CPAA.S48530.
https://psnet.ahrq.gov/issue/reducing-medication-errors-critical-care-multim…
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psnet.ahrq.gov/node/45630/psn-pdf
March 29, 2017 - Do leadership style, unit climate, and safety climate
contribute to safe medication practices?
March 29, 2017
Farag A, Tullai-McGuinness S, Anthony MK, et al. Do Leadership Style, Unit Climate, and Safety Climate
Contribute to Safe Medication Practices? J Nurs Adm. 2017;47(1):8-15.
https://psnet.ahrq.gov/issue/do-…
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psnet.ahrq.gov/node/836753/psn-pdf
March 16, 2022 - Inequities in quality and safety outcomes for hospitalized
children with intellectual disability.
March 16, 2022
Mimmo L, Harrison R, Travaglia J, et al. Inequities in quality and safety outcomes for hospitalized children
with intellectual disability. Dev Med Child Neurol. 2022;64(3):314-322. doi:10.1111/dmcn.15066…
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psnet.ahrq.gov/node/50378/psn-pdf
September 25, 2019 - Evaluating horizontal violence and bullying in the nursing
workforce of an oncology academic medical center.
September 25, 2019
Lewis-Pierre LT, Anglade D, Saber D, et al. Evaluating horizontal violence and bullying in the nursing
workforce of an oncology academic medical center. J Nurs Manag. 2019;27(5):1005-1010.…
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psnet.ahrq.gov/node/47279/psn-pdf
July 23, 2018 - No Place Like Home: Advancing the Safety of Care in the
Home.
July 23, 2018
Boston, MA: Institute for Healthcare Improvement; 2018.
https://psnet.ahrq.gov/issue/no-place-home-advancing-safety-care-home
The home care setting harbors unique challenges to patient safety. This report builds on a previous
evidence ass…