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psnet.ahrq.gov/issue/antecedents-willingness-report-medical-treatment-errors-health-care-organizations-multilevel
May 06, 2015 - Commentary
Antecedents of willingness to report medical treatment errors in health care organizations: a multilevel theoretical framework.
Citation Text:
Naveh E, Katz-Navon T. Antecedents of willingness to report medical treatment errors in health care organizations: a multilevel theo…
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psnet.ahrq.gov/issue/analysis-laboratory-critical-value-reporting-large-academic-medical-center
December 05, 2013 - Study
Analysis of laboratory critical value reporting at a large academic medical center.
Citation Text:
Dighe AS, Rao A, Coakley AB, et al. Analysis of laboratory critical value reporting at a large academic medical center. Am J Clin Pathol. 2006;125(5):758-64.
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psnet.ahrq.gov/issue/treatment-errors-healthcare-safety-climate-approach
July 13, 2010 - Study
Treatment errors in healthcare: a safety climate approach.
Citation Text:
Naveh E, Katz-Navon T, Stern Z. Treatment errors in healthcare: a safety climate approach. . Manage Sci. 2005;51(6):948-960. doi:10.1287/mnsc.1050.0372.
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psnet.ahrq.gov/issue/hospital-patient-safety-characteristics-best-performing-hospitals
February 03, 2011 - Study
Hospital patient safety: characteristics of best-performing hospitals.
Citation Text:
Longo DR, Hewett JE, Ge B, et al. Hospital patient safety: characteristics of best-performing hospitals. J Healthc Manag. 2007;52(3):188-204; discussion 204-5.
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psnet.ahrq.gov/issue/normalization-deviance-threat-patient-safety
December 21, 2016 - Commentary
The normalization of deviance: a threat to patient safety.
Citation Text:
Odom-Forren J. The normalization of deviance: a threat to patient safety. J Perianesth Nurs. 2011;26(3):216-9. doi:10.1016/j.jopan.2011.05.002.
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psnet.ahrq.gov/issue/role-patient-patient-safety-what-can-we-learn-healthcares-history
June 12, 2024 - Commentary
The role of the patient in patient safety: what can we learn from healthcare's history?
Citation Text:
Leistikow I, Huisman F. The role of the patient in patient safety: What can we learn from healthcare's history? J Patient Saf Risk Manag. 2018;23(4):139-141. doi:10.1177/2516…
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psnet.ahrq.gov/issue/learning-accidents-what-more-do-we-need-know
May 29, 2014 - Commentary
Learning from accidents—what more do we need to know?
Citation Text:
Lindberg A-K, Hansson SO, Rollenhagen C. Learning from accidents – What more do we need to know? Saf Sci. 2010;48(6). doi:10.1016/j.ssci.2010.02.004.
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psnet.ahrq.gov/issue/guidelines-prevention-intravascular-catheter-related-infections
January 22, 2014 - Clinical Guideline
Guidelines for the prevention of intravascular catheter-related infections.
Citation Text:
O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. American journal of infection control. 2011;39(4 Suppl 1):…
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psnet.ahrq.gov/issue/implementing-safety-hotlines-stamford-healths-experience-and-future-opportunities
March 23, 2011 - Commentary
Implementing safety hotlines: Stamford Health's experience and future opportunities.
Citation Text:
Cardiello R, Johnston S, Kiely S. Implementing safety hotlines: Stamford Health's experience and future opportunities. J Healthc Risk Manag. 2019;38(3):24-31. doi:10.1002/jhrm.2…
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psnet.ahrq.gov/issue/patient-safety-climate-92-us-hospitals-differences-work-area-and-discipline
September 02, 2009 - Study
Patient safety climate in 92 US hospitals: differences by work area and discipline.
Citation Text:
Singer SJ, Gaba DM, Falwell A, et al. Patient safety climate in 92 US hospitals: differences by work area and discipline. Med Care. 2009;47(1):23-31. doi:10.1097/MLR.0b013e31817e189…
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psnet.ahrq.gov/issue/risk-care-plans-way-reduce-readmissions-and-adverse-events
October 27, 2010 - Commentary
At risk care plans: a way to reduce readmissions and adverse events.
Citation Text:
Bahle J, Majercik C, Ludwick R, et al. At Risk Care Plans: a way to reduce readmissions and adverse events. J Nurs Care Qual. 2015;30(3):200-4. doi:10.1097/NCQ.0000000000000106.
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psnet.ahrq.gov/issue/does-unit-shift-report-blackout-period-improve-patient-safety
August 04, 2021 - Commentary
Does a unit shift report "blackout" period improve patient safety?
Citation Text:
Olmstead J. Does a unit shift report "blackout" period improve patient safety? Nurs Manage. 2019;50(3):8-10. doi:10.1097/01.NUMA.0000553500.85897.51.
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psnet.ahrq.gov/issue/it-left-eye-right
September 06, 2023 - Study
"It is the left eye, right?"
Citation Text:
Pikkel D, Sharabi-Nov A, Pikkel J. "It is the left eye, right?". Risk Manag Healthc Policy. 2014;7:77-80. doi:10.2147/RMHP.S60728.
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psnet.ahrq.gov/web-mm/crossed-coverage
September 01, 2015 - Crossed Coverage
Citation Text:
Kayser SR. Crossed Coverage. 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/node/49420/psn-pdf
October 01, 2003 - To LP or Not LP
October 1, 2003
Landrigan CP. To LP or Not LP. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/lp-or-not-lp
The Case
A 4-month-old male infant was seen in the office setting of a large multisite practice. He presented with
fever and irritability without an obvious source. He was referred to …
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psnet.ahrq.gov/node/841468/psn-pdf
December 14, 2022 - Don’t Bite Your Tongue.
December 14, 2022
Singh NS. Don’t Bite Your Tongue. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/dont-bite-your-tongue
The Case
A 63-year-old woman with a past medical history of hypertension, osteoarthritis, migraine headaches, and
daily smoking was admitted to a hospital for ant…
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psnet.ahrq.gov/node/43452/psn-pdf
August 20, 2014 - Electronic health record–related safety concerns: a cross-
sectional survey.
August 20, 2014
Menon S, Singh H, Meyer AND, et al. Electronic health record-related safety concerns: a cross-sectional
survey. J Healthc Risk Manag. 2014;34(1):14-26. doi:10.1002/jhrm.21146.
https://psnet.ahrq.gov/issue/electronic-health…
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psnet.ahrq.gov/node/43386/psn-pdf
January 20, 2016 - The influence of organizational factors on patient safety:
examining successful handoffs in health care.
January 20, 2016
Richter J, McAlearney AS, Pennell ML. The influence of organizational factors on patient safety: Examining
successful handoffs in health care. Health Care Manage Rev. 2016;41(1):32-41.
doi:10.1…
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psnet.ahrq.gov/issue/equipped-overcoming-barriers-change-improve-quality-care-theories-change
May 23, 2018 - Commentary
Equipped: overcoming barriers to change to improve quality of care (theories of change).
Citation Text:
Lachman P, Runnacles J, Dudley J, et al. Equipped: overcoming barriers to change to improve quality of care (theories of change). Arch Dis Child Educ Pract Ed. 2015;100(1):1…
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psnet.ahrq.gov/issue/outcomes-michigan-medicines-integrated-patient-safety-and-communication-and-resolution
April 24, 2018 - Study
Outcomes of Michigan Medicine's integrated patient safety and communication and resolution program, 2013–2022.
Citation Text:
Burney RE, Mckeown ES, Zhang Y, et al. Outcomes of Michigan Medicine's integrated patient safety and communication and resolution program, 2013–2022. J Pati…