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psnet.ahrq.gov/node/45834/psn-pdf
February 22, 2017 - Implementing an error disclosure coaching model: a
multicenter case study.
February 22, 2017
White AA, Brock DM, McCotter PI, et al. Implementing an error disclosure coaching model: A multicenter
case study. J Healthc Risk Manag. 2017;36(3):34-45. doi:10.1002/jhrm.21260.
https://psnet.ahrq.gov/issue/implementing-e…
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psnet.ahrq.gov/node/42743/psn-pdf
November 20, 2013 - Enhance patient safety by identifying and minimizing risk
exposures affecting nurse practitioner practice.
November 20, 2013
Leigh J, Flynn J. Enhance patient safety by identifying and minimizing risk exposures affecting nurse
practitioner practice. J Healthc Risk Manag. 2013;33(2):27-35. doi:10.1002/jhrm.21124.
h…
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psnet.ahrq.gov/node/43230/psn-pdf
July 15, 2014 - Hospital deaths in patients with sepsis from 2
independent cohorts.
July 15, 2014
Liu V, Escobar GJ, Greene JD, et al. Hospital deaths in patients with sepsis from 2 independent cohorts.
JAMA. 2014;312(1):90-2.
https://psnet.ahrq.gov/issue/hospital-deaths-patients-sepsis-2-independent-cohorts
This study used nati…
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psnet.ahrq.gov/node/46316/psn-pdf
August 02, 2017 - Defending a "never event."
August 2, 2017
Shepperd JR. Defending a "Never Event". J Healthc Risk Manag. 2017;37(1):17-22.
doi:10.1002/jhrm.21277.
https://psnet.ahrq.gov/issue/defending-never-event
Surgical fires are considered a never event. This commentary provides an overview of surgical fires,
explains element…
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psnet.ahrq.gov/node/44135/psn-pdf
November 06, 2015 - Freedom to Speak Up: A Review of Whistleblowing in the
NHS.
November 6, 2015
Francis R. London, UK: Department of Health; February 2015.
https://psnet.ahrq.gov/issue/freedom-speak-review-whistleblowing-nhs
Staff willingness to raise awareness of problems that could affect patient care is an important indicator of
…
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psnet.ahrq.gov/node/44783/psn-pdf
January 13, 2016 - Black Box Thinking: Why Most People Never Learn From
Their Mistakes—But Some Do.
January 13, 2016
Syed M. New York, NY: Portfolio; 2015. ISBN: 9781591848226.
https://psnet.ahrq.gov/issue/black-box-thinking-why-most-people-never-learn-their-mistakes-some-do
Medicine and aviation are high-risk industries where failu…
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psnet.ahrq.gov/node/35495/psn-pdf
February 22, 2010 - The Patient Safety Institute demonstration project: a
model for implementing a local health information
infrastructure.
February 22, 2010
Classen D, Kanhouwa M, Will D, et al. The patient safety institute demonstration project: a model for
implementing a local health information infrastructure. J Healthc Inf Manag…
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psnet.ahrq.gov/node/38213/psn-pdf
November 12, 2008 - AHRQ announces interest in research on diagnostic
errors in ambulatory care settings.
November 12, 2008
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 25, 2007.
Publication No. NOT-HS-08-002.
https://psnet.ahrq.gov/issue/ahrq-announces-interest-research-diagnostic-error…
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psnet.ahrq.gov/node/837676/psn-pdf
July 13, 2022 - Safety-II and the study of healthcare safety routines: two
paths forward for research.
July 13, 2022
Rydenfält C. Safety-II and the study of healthcare safety routines: two paths forward for research. J Patient
Saf Risk Manag. 2022;27(3):124-128. doi:10.1177/25160435221102129.
https://psnet.ahrq.gov/issue/safety-i…
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psnet.ahrq.gov/node/36936/psn-pdf
September 09, 2011 - Development of a patient safety culture measurement tool
for ambulatory health care settings: analysis of content
validity.
September 9, 2011
Schutz AL, Counte MA, Meurer S. Development of a patient safety culture measurement tool for
ambulatory health care settings: analysis of content validity. Health Care Manag…
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psnet.ahrq.gov/node/42559/psn-pdf
May 28, 2014 - Safeguarding in medication administration:
understanding pre-registration nursing students' survey
response to patient safety and peer reporting issues.
May 28, 2014
Andrew S, Mansour M. Safeguarding in medication administration: understanding pre-registration nursing
students' survey response to patient safety an…
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psnet.ahrq.gov/node/74214/psn-pdf
December 29, 2020 - Racial and ethnic disparities in the treatment of chronic
pain.
December 29, 2020
Morales ME, Yong RJ. Racial and ethnic disparities in the treatment of chronic pain. Pain Med.
2020;22(1):75-90. doi:10.1093/pm/pnaa427.
https://psnet.ahrq.gov/issue/racial-and-ethnic-disparities-treatment-chronic-pain
This literatu…
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psnet.ahrq.gov/node/843090/psn-pdf
January 25, 2023 - Bleeding and in pain, a pregnant woman in Louisiana
couldn’t get answers.
January 25, 2023
Westwood R. Kaiser Health News. January 12, 2023.
https://psnet.ahrq.gov/issue/bleeding-and-pain-pregnant-woman-louisiana-couldnt-get-answers
Lack of access to obstetric care impedes safe treatment for mothers. This story de…
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psnet.ahrq.gov/node/42253/psn-pdf
May 08, 2013 - Using inpatient hospital discharge data to monitor patient
safety events.
May 8, 2013
Taylor JA, Pandian RS, Mao L, et al. Using inpatient hospital discharge data to monitor patient safety
events. J Healthc Risk Manag. 2013;32(4):26-33. doi:10.1002/jhrm.21107.
https://psnet.ahrq.gov/issue/using-inpatient-hospital-…
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psnet.ahrq.gov/node/36638/psn-pdf
January 14, 2011 - Health care work environments, employee satisfaction,
and patient safety: care provider perspectives.
January 14, 2011
Rathert C, May DR. Health care work environments, employee satisfaction, and patient safety: care
provider perspectives. Health Care Manage Rev. 2007;32(1):2-11.
https://psnet.ahrq.gov/issue/healt…
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psnet.ahrq.gov/node/37760/psn-pdf
May 14, 2008 - The role of continuous quality improvement and
psychological safety in predicting work-arounds.
May 14, 2008
Halbesleben JRB, Rathert C. The role of continuous quality improvement and psychological safety in
predicting work-arounds. Health Care Manage Rev. 2008;33(2):134-44.
doi:10.1097/01.HMR.0000304505.04932.62.…
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psnet.ahrq.gov/node/45606/psn-pdf
October 27, 2016 - Unprofessional workplace conduct...defining and
defusing it.
October 27, 2016
MacLean L, Coombs C, Breda K. Unprofessional workplace conduct..defining and defusing it. Nurs
Manage. 2016;47(9):30-34. doi:10.1097/01.NUMA.0000491126.68354.be.
https://psnet.ahrq.gov/issue/unprofessional-workplace-conductdefining-and-d…
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psnet.ahrq.gov/node/46605/psn-pdf
January 24, 2018 - The impact of interruptions on medication errors in
hospitals: an observational study of nurses.
January 24, 2018
Johnson M, Sanchez P, Langdon R, et al. The impact of interruptions on medication errors in hospitals: an
observational study of nurses. J Nurs Manag. 2017;25(7):498-507. doi:10.1111/jonm.12486.
https:…
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psnet.ahrq.gov/node/34036/psn-pdf
March 28, 2005 - National Center for Patient Safety Falls Toolkit 2004.
March 28, 2005
Department of Veterans Affairs (VA) National Center for Patient Safety
https://psnet.ahrq.gov/issue/national-center-patient-safety-falls-toolkit-2004
The National Center for Patient Safety created the Falls Toolkit to assist VA facilities in impl…
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psnet.ahrq.gov/node/48166/psn-pdf
August 28, 2019 - Doctors can change opioid prescribing habits, but
progress comes in small doses.
August 28, 2019
Appleby J; Lucas E.
https://psnet.ahrq.gov/issue/doctors-can-change-opioid-prescribing-habits-progress-comes-small-doses
Efforts to reduce misuse of prescription opioids must draw from public health and behavioral stra…