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psnet.ahrq.gov/issue/do-eps-change-their-clinical-behaviour-hallway-or-when-companion-present-cross-sectional
June 29, 2022 - Study
Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey.
Citation Text:
Stoklosa H, Scannell M, Ma Z, et al. Do EPs change their clinical behaviour in the hallway or when a companion is present? A cross-sectional survey. Emerg …
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psnet.ahrq.gov/issue/identification-hospital-complications-claims-data-it-valid
June 13, 2011 - Study
Classic
Identification of in-hospital complications from claims data. Is it valid?
Citation Text:
Lawthers AG, McCarthy EP, Davis RB, et al. Identification of in-hospital complications from claims data. Is it valid? Med Care. 2000;38(8):785-95.
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psnet.ahrq.gov/issue/systematic-review-types-safety-incidents-and-processes-and-systems-used-safety-incident
September 11, 2024 - Review
Systematic review of types of safety incidents and the processes and systems used for safety incident reporting in care homes.
Citation Text:
Scott J, Sykes K, Waring J, et al. Systematic review of types of safety incidents and the processes and systems used for safety incident re…
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psnet.ahrq.gov/issue/exploring-attitudes-and-opinions-pharmacists-toward-delivering-prescribing-error-feedback
January 16, 2019 - Study
Exploring attitudes and opinions of pharmacists toward delivering prescribing error feedback: a qualitative case study using focus group interviews.
Citation Text:
Lloyd M, Watmough SD, O'Brien S, et al. Exploring attitudes and opinions of pharmacists toward delivering prescribing …
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psnet.ahrq.gov/issue/pharmacists-perceptions-error-reporting-systems
November 09, 2016 - Study
Pharmacists’ perceptions of error reporting systems.
Citation Text:
Hartt CM, Weigand H, MacDonald AJ, et al. Pharmacists’ perceptions of error reporting systems. J Patient Saf Risk Manag. 2024;29(6):268-273. doi:10.1177/25160435241288287.
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psnet.ahrq.gov/issue/simulating-quality-centralized-quality-improvement-and-patient-safety-simulation-curriculum
January 03, 2017 - Study
Simulating for quality: a centralized quality improvement and patient safety simulation curriculum for residents and fellows.
Citation Text:
Luty JT, Oldham H, Smeraglio A, et al. Simulating for quality: a centralized quality improvement and patient safety simulation curriculum for…
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psnet.ahrq.gov/issue/sustaining-improvement-hospital-wide-initiative-patient-safety-and-quality-systematic-scoping
September 01, 2021 - Review
Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review.
Citation Text:
Moon SEJ, Hogden A, Eljiz K. Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review. BMJ Open Qual…
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psnet.ahrq.gov/issue/using-patient-experience-surveys-identify-potential-diagnostic-safety-breakdowns-mixed
October 30, 2024 - Study
Using patient experience surveys to identify potential diagnostic safety breakdowns: a mixed methods study.
Citation Text:
Baker KM, Brahier M, Penne M, et al. Using patient experience surveys to identify potential diagnostic safety breakdowns: a mixed methods study. J Patient Saf.…
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psnet.ahrq.gov/issue/good-practice-guides-medication-errors-part-1-and-part-2
August 03, 2016 - Book/Report
Good Practice Guides on Medication Errors: Part 1 and Part 2.
Citation Text:
Goedecke T, Ord K, Newbould V, et al. Medication Errors: New Eu Good Practice Guide On Risk Minimisation And Error Prevention. Springer Science and Business Media LLC; 2016. doi:10.1007/s40264-016-04…
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psnet.ahrq.gov/issue/use-hit-adverse-event-reporting-nursing-homes-barriers-and-facilitators
June 02, 2010 - Study
Use of HIT for adverse event reporting in nursing homes: barriers and facilitators.
Citation Text:
Wagner LM, Castle NG, Handler S. Use of HIT for adverse event reporting in nursing homes: barriers and facilitators. Geriatr Nurs. 2013;34(2):112-5. doi:10.1016/j.gerinurse.2012.10.…
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psnet.ahrq.gov/node/46297/psn-pdf
March 21, 2018 - Reasons for computerised provider order entry (CPOE)-
based inpatient medication ordering errors: an
observational study of voided orders.
March 21, 2018
Abraham J, Kannampallil TG, Jarman A, et al. Reasons for computerised provider order entry (CPOE)-
based inpatient medication ordering errors: an observational s…
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psnet.ahrq.gov/node/48139/psn-pdf
July 17, 2019 - 'Poking the skunk': ethical and medico-legal concerns in
research about patients' experiences of medical injury.
July 17, 2019
Moore JS, Mello MM, Bismark M. 'Poking the skunk': Ethical and medico-legal concerns in research about
patients' experiences of medical injury. Bioethics. 2019;33(8):948-957. doi:10.1111/bi…
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psnet.ahrq.gov/node/47694/psn-pdf
February 06, 2019 - Association of pharmaceutical industry marketing of
opioid products with mortality from opioid-related
overdoses.
February 6, 2019
Hadland SE, Rivera-Aguirre A, Marshall BDL, et al. Association of Pharmaceutical Industry Marketing of
Opioid Products With Mortality From Opioid-Related Overdoses. JAMA Netw Open. 201…
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
March 24, 2025 - I think understanding what happened and what could have been done, or the lessons that might be learned
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psnet.ahrq.gov/node/33764/psn-pdf
April 01, 2014 - I see the role of
NPSF in this new arena as taking what's being learned from the Hospital Engagement
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psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Rethinking Root Cause Analysis
January 1, 2016
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
Annual Perspective 2016
Introduction
Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
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psnet.ahrq.gov/node/60547/psn-pdf
May 28, 2020 - The Role of the FDA in Ensuring Device Safety
May 28, 2020
Fitall E, Hall KK, Gale B. The Role of the FDA in Ensuring Device Safety . PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
Introduction
The Food and Drug Administration (FDA) plays a critical role in ensuring the …
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - SPOTLIGHT CASE
Failure to Report
Citation Text:
Spath P. Failure to Report. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program
June 01, 2018 - We look at what they want to learn and what scans can be performed relatively quickly and learned well
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psnet.ahrq.gov/node/45293/psn-pdf
February 01, 2017 - Patient safety incidents involving sick children in primary
care in England and Wales: a mixed methods analysis.
February 1, 2017
Rees P, Edwards A, Powell C, et al. Patient Safety Incidents Involving Sick Children in Primary Care in
England and Wales: A Mixed Methods Analysis. PLoS Med. 2017;14(1):e1002217.
doi:1…