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psnet.ahrq.gov/node/34933/psn-pdf
April 06, 2011 - Insights from the sharp end of intravenous medication
errors: implications for infusion pump technology.
April 6, 2011
Husch M. Insights from the sharp end of intravenous medication errors: implications for infusion pump
technology. Quality and Safety in Health Care. 2005;14(2). doi:10.1136/qshc.2004.011957.
https…
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psnet.ahrq.gov/node/73699/psn-pdf
September 15, 2021 - Making safety training stickier: a richer model of safety
training engagement and transfer.
September 15, 2021
Casey T, Turner N, Hu X, et al. Making safety training stickier: a richer model of safety training engagement
and transfer. J Safety Res. 2021;78:303-313. doi:10.1016/j.jsr.2021.06.004.
https://psnet.ahrq…
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psnet.ahrq.gov/node/74856/psn-pdf
February 23, 2022 - The secondary use of data to support medication safety
in the hospital setting: a systematic review and narrative
synthesis.
February 23, 2022
Chaudhry NT, Franklin BD, Mohammed S, et al. The secondary use of data to support medication safety in
the hospital setting: a systematic review and narrative synthesis. Ph…
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psnet.ahrq.gov/node/50801/psn-pdf
January 15, 2020 - Demonstrating the value of postgraduate fellowships for
physicians in quality improvement and patient safety.
January 15, 2020
Myers JS, Lane-Fall MB, Perfetti AR, et al. Demonstrating the value of postgraduate fellowships for
physicians in quality improvement and patient safety. BMJ Qual Saf. 2020;29(8):645-654.
…
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psnet.ahrq.gov/node/865594/psn-pdf
January 01, 2025 - Understanding the informal aspects of medication
processes to maintain patient safety in hospitals: a
sociotechnical ethnographic study in paediatric units.
April 17, 2024
Sutherland AB, Phipps DL, Grant S, et al. Understanding the informal aspects of medication processes to
maintain patient safety in hospitals: a…
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psnet.ahrq.gov/node/866557/psn-pdf
August 21, 2024 - Minimization of occurrence of retained surgical items
using machine learning and deep learning techniques: a
review.
August 21, 2024
Abo-Zahhad M, El-Malek AHA, Sayed MS, et al. Minimization of occurrence of retained surgical items
using machine learning and deep learning techniques: a review. BioData Min. 2024;17…
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psnet.ahrq.gov/node/840152/psn-pdf
November 16, 2022 - Scientific view of the global literature on medical error
reporting and reporting systems from 1977 to 2021: a
bibliometric analysis.
November 16, 2022
Ünal A, Seren Intepeler ?. Scientific view of the global literature on medical error reporting and reporting
systems from 1977 to 2021: a bibliometric analysis. J …
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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/35251/psn-pdf
April 06, 2011 - Promoting health care safety through training high
reliability teams.
April 6, 2011
Wilson KA. Promoting health care safety through training high reliability teams. Quality and Safety in Health
Care. 2005;14(4). doi:10.1136/qshc.2004.010090.
https://psnet.ahrq.gov/issue/promoting-health-care-safety-through-trainin…
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psnet.ahrq.gov/node/34670/psn-pdf
January 01, 2006 - Hindsight ? foresight: the effect of outcome knowledge
on judgment under uncertainty.
March 7, 2005
Fischhoff B. Hindsight is not equal to foresight: The effect of outcome knowledge on judgment under
uncertainty. Journal of Experimental Psychology: Human Perception and Performance. 2006;1(3).
doi:10.1037/0096-1523…
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psnet.ahrq.gov/node/47106/psn-pdf
August 15, 2018 - Imitating incidents: how simulation can improve safety
investigation and learning from adverse events.
August 15, 2018
Macrae C. Imitating Incidents: How Simulation Can Improve Safety Investigation and Learning From
Adverse Events. Simul Healthc. 2018;13(4):227-232. doi:10.1097/SIH.0000000000000315.
https://psnet.…
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psnet.ahrq.gov/node/866254/psn-pdf
July 10, 2024 - Top Penn State Health surgeon warned leaders about
transplant problems months before shutdown. Then he
was let go.
July 10, 2024
Massey W, Keith C. Spotlight PA: June 20, 2024.
https://psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems-
months-shutdown-then
Whistleblowers…
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psnet.ahrq.gov/node/45504/psn-pdf
January 01, 2018 - Hospital nurses' work environment characteristics and
patient safety outcomes: a literature review.
December 16, 2017
Lee SE, Scott LD. Hospital Nurses' Work Environment Characteristics and Patient Safety Outcomes: A
Literature Review. West J Nurs Res. 2018;40(1):121-145. doi:10.1177/0193945916666071.
https://psne…
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psnet.ahrq.gov/node/41166/psn-pdf
February 29, 2012 - Triangulating case-finding tools for patient safety
surveillance: a cross-sectional case study of
puncture/laceration.
February 29, 2012
Taylor JA, Gerwin D, Morlock L, et al. Triangulating case-finding tools for patient safety surveillance: a
cross-sectional case study of puncture/laceration. Inj Prev. 2011;17(6)…
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www.uspreventiveservicestaskforce.org/uspstf/update-on-methods-insufficient-evidence---table-2
February 01, 2009 - Update on Methods: Insufficient Evidence - Table 2
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Table 2. The 4 Domains of Information Pertinent to Clinical Decisionmaking for Preventive Services
Domain
Descrip…
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www.uspreventiveservicestaskforce.org/uspstf/integrating-evidence-based-clinical-and-community-strategies-to-improve-health---table-1
November 01, 2013 - Integrating Evidence-Based Clinical and Community Strategies to Improve Health - Table 1
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The Leading and Actual Causes of Death, United States, 2000
Leading cause of …
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psnet.ahrq.gov/node/48073/psn-pdf
June 19, 2019 - Special Section on Human Factors and Ergonomics in the
Operating Room: Contributions That Advance Surgical
Practice.
June 19, 2019
Hallbeck MS, Paquet V, eds. Appl Ergon. 2019;78:248-308.
https://psnet.ahrq.gov/issue/special-section-human-factors-and-ergonomics-operating-room-contributions-
advance-surgical
Surg…
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psnet.ahrq.gov/node/50910/psn-pdf
February 19, 2020 - SEIPS 3.0: human-centered design of the patient journey
for patient safety.
February 19, 2020
Carayon P, Wooldridge AR, Hoonakker P, et al. SEIPS 3.0: human-centered design of the patient journey
for patient safety. App Ergon. 2020;84:103033. doi:10.1016/j.apergo.2019.103033.
https://psnet.ahrq.gov/issue/seips-30-…
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psnet.ahrq.gov/node/50943/psn-pdf
February 26, 2020 - Learning from complaints in healthcare: a realist review
of academic literature, policy evidence and front-line
insights.
February 26, 2020
van Dael J, Reader TW, Gillespie A, et al. Learning from complaints in healthcare: a realist review of
academic literature, policy evidence and front-line insights. BMJ Qual S…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/improve/teams-infographic.pdf
March 01, 2017 - Remember T.E.A.M.S. to Improve Safety Culture
T
E
A
M
S
Team
Formation
Excellent
Communication
Assess
What’s
Working
Meet
Monthly
Sustain
Efforts
The most effective teams are diverse. Make sure
your team includes people of differing perspectives
and roles.
Communication should be effective. Commu…