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psnet.ahrq.gov/node/46191/psn-pdf
July 19, 2017 - Performance of a trigger tool for identifying adverse
events in oncology.
July 19, 2017
Lipitz-Snyderman A, Classen D, Pfister D, et al. Performance of a Trigger Tool for Identifying Adverse
Events in Oncology. J Oncol Pract. 2017;13(3). doi:10.1200/jop.2016.016634.
https://psnet.ahrq.gov/issue/performance-trigger…
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psnet.ahrq.gov/node/39210/psn-pdf
January 12, 2010 - Can aviation-based team training elicit sustainable
behavioral change?
January 12, 2010
Sax HC, Browne P, Mayewski RJ, et al. Can aviation-based team training elicit sustainable behavioral
change? Arch Surg. 2009;144(12):1133-1137. doi:10.1001/archsurg.2009.207.
https://psnet.ahrq.gov/issue/can-aviation-based-team…
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psnet.ahrq.gov/node/39873/psn-pdf
January 22, 2017 - A proactive risk avoidance system using failure mode and
effects analysis for "same-name" physician orders.
January 22, 2017
Tarpey K, Schaaf E, Lakhani U, et al. A proactive risk avoidance system using failure mode and effects
analysis for "same-name" physician orders. Jt Comm J Qual Patient Saf. 2010;36(10):461-7…
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psnet.ahrq.gov/node/39892/psn-pdf
September 20, 2011 - How does routine disclosure of medical error affect
patients' propensity to sue and their assessment of
provider quality?: Evidence from survey data.
September 20, 2011
Helmchen LA, Richards MR, McDonald TB. How does routine disclosure of medical error affect patients'
propensity to sue and their assessment of pro…
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psnet.ahrq.gov/node/37808/psn-pdf
February 22, 2011 - How do hospitalized patients feel about resident work
hours, fatigue, and discontinuity of care?
February 22, 2011
Fletcher KE, Wiest FC, Halasyamani L, et al. How do hospitalized patients feel about resident work hours,
fatigue, and discontinuity of care? J Gen Intern Med. 2008;23(5):623-8. doi:10.1007/s11606-007-…
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psnet.ahrq.gov/node/44315/psn-pdf
November 20, 2015 - Expanding the scope of Critical Care Rapid Response
Teams: a feasible approach to identify adverse events. A
prospective observational cohort.
November 20, 2015
Amaral ACK-B, McDonald A, Coburn NG, et al. Expanding the scope of Critical Care Rapid Response
Teams: a feasible approach to identify adverse events. A p…
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psnet.ahrq.gov/node/34112/psn-pdf
February 09, 2011 - Excess length of stay, charges, and mortality attributable
to medical injuries during hospitalization.
February 9, 2011
Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during
hospitalization. JAMA. 2003;290(14):1868-74.
https://psnet.ahrq.gov/issue/excess-length-st…
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psnet.ahrq.gov/node/41775/psn-pdf
December 18, 2014 - Measuring adverse events and levels of harm in pediatric
inpatients with the Global Trigger Tool.
December 18, 2014
Kirkendall E, Kloppenborg E, Papp J, et al. Measuring adverse events and levels of harm in pediatric
inpatients with the Global Trigger Tool. Pediatrics. 2012;130(5):e1206-14. doi:10.1542/peds.2012-01…
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psnet.ahrq.gov/node/39852/psn-pdf
February 10, 2015 - National costs of the medical liability system.
February 10, 2015
Mello MM, Chandra A, Gawande AA, et al. National costs of the medical liability system. Health Aff
(Millwood). 2010;29(9):1569-1577. doi:10.1377/hlthaff.2009.0807.
https://psnet.ahrq.gov/issue/national-costs-medical-liability-system
The role of medi…
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psnet.ahrq.gov/node/39777/psn-pdf
November 04, 2012 - The Economic Measurement of Medical Errors.
November 4, 2012
Shreve J, van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E. Schaumburg, IL: The Society of
Actuaries; 2010.
https://psnet.ahrq.gov/issue/economic-measurement-medical-errors
Although the Institute of Medicine's estimate of up to 98,000 deaths ye…
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psnet.ahrq.gov/node/43367/psn-pdf
May 01, 2015 - Promoting Patient Safety Through Effective Health
Information Technology Risk Management.
May 1, 2015
Schneider EC, Ridgely MS, Meeker D, Hunter LE, Khodyakov D, Rudin R. RAND Health. Washington, DC:
Office of the National Coordinator for Health Information Technology; May 2014. RR-654-DHHSNCH.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/44972/psn-pdf
February 15, 2017 - The effectiveness of electronic differential diagnoses
(DDX) generators: a systematic review and meta-analysis.
February 15, 2017
Riches N, Panagioti M, Alam R, et al. The Effectiveness of Electronic Differential Diagnoses (DDX)
Generators: A Systematic Review and Meta-Analysis. PLoS One. 2016;11(3):e0148991.
doi:…
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psnet.ahrq.gov/node/846158/psn-pdf
March 15, 2023 - Safety risks and workflow implications associated with
nursing-related free-text communication orders.
March 15, 2023
Staes CJ, Yusuf S, Hambly M, et al. Safety risks and workflow implications associated with nursing-related
free-text communication orders. J Am Med Inform Assoc. 2023;30(5):828-837. doi:10.1093/jami…
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psnet.ahrq.gov/node/39083/psn-pdf
April 01, 2010 - Emergency physician perceptions of patient safety risks.
April 1, 2010
Sklar DP, Crandall CS, Zola T, et al. Emergency physician perceptions of patient safety risks. Ann Emerg
Med. 2010;55(4):336-40. doi:10.1016/j.annemergmed.2009.08.020.
https://psnet.ahrq.gov/issue/emergency-physician-perceptions-patient-safety-r…
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psnet.ahrq.gov/node/46700/psn-pdf
November 19, 2018 - Promising practices for improving hospital patient safety
culture.
November 19, 2018
Campione J, Famolaro T. Promising Practices for Improving Hospital Patient Safety Culture. Jt Comm J
Qual Patient Saf. 2018;44(1):23-32. doi:10.1016/j.jcjq.2017.09.001.
https://psnet.ahrq.gov/issue/promising-practices-improving-ho…
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psnet.ahrq.gov/node/38206/psn-pdf
January 15, 2009 - The medical emergency team system and not-for-
resuscitation orders: results from the MERIT Study.
January 15, 2009
Chen J, Flabouris A, Bellomo R, et al. The Medical Emergency Team System and not-for-resuscitation
orders: results from the MERIT study. Resuscitation. 2008;79(3):391-7.
doi:10.1016/j.resuscitation.2…
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psnet.ahrq.gov/node/37945/psn-pdf
July 26, 2010 - A survey of hospital quality improvement activities.
July 26, 2010
Cohen AB, Restuccia JD, Shwartz M, et al. A survey of hospital quality improvement activities. Med Care
Res Rev. 2008;65(5):571-95. doi:10.1177/1077558708318285.
https://psnet.ahrq.gov/issue/survey-hospital-quality-improvement-activities
The Instit…
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psnet.ahrq.gov/node/36907/psn-pdf
September 14, 2012 - Serious Reportable Events in Healthcare—2011 Update.
September 14, 2012
Washington DC: National Quality Forum; December 2011.
https://psnet.ahrq.gov/issue/serious-reportable-events-healthcare-2011-update
The National Quality Forum originally defined 27 health care "never events"—patient safety events that
pose ser…
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psnet.ahrq.gov/node/36105/psn-pdf
May 27, 2011 - Computerized provider order entry implementation: no
association with increased mortality rates in an intensive
care unit.
May 27, 2011
Del Beccaro MA, Jeffries HE, Eisenberg MA, et al. Computerized provider order entry implementation: no
association with increased mortality rates in an intensive care unit. Pediat…
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psnet.ahrq.gov/node/36530/psn-pdf
January 07, 2011 - Impact of extended-duration shifts on medical errors,
adverse events, and attentional failures.
January 7, 2011
Barger LK, Ayas N, Cade BE, et al. Impact of extended-duration shifts on medical errors, adverse events,
and attentional failures. PLoS Med. 2006;3(12):e487.
https://psnet.ahrq.gov/issue/impact-extended-…