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psnet.ahrq.gov/node/38083/psn-pdf
September 24, 2008 - Sources and types of discrepancies between electronic
medical records and actual outpatient medication use.
September 24, 2008
Orrico KB. Sources and types of discrepancies between electronic medical records and actual outpatient
medication use. J Manag Care Pharm. 2008;14(7):626-631.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/44057/psn-pdf
June 03, 2015 - Measuring nursing error: psychometrics of MISSCARE
and practice and professional issues items.
June 3, 2015
Castner J, Dean-Baar S. Measuring nursing error: psychometrics of MISSCARE and practice and
professional issues items. J Nurs Manag. 2014;22(3):421-437.
https://psnet.ahrq.gov/issue/measuring-nursing-error-p…
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psnet.ahrq.gov/node/40883/psn-pdf
February 10, 2012 - Consensus statement on effective communication of
urgent diagnoses and significant, unexpected diagnoses
in surgical pathology and cytopathology from the College
of American Pathologists and Association of Directors of
Anatomic and Surgical Pathology.
February 10, 2012
Nakhleh RE, Myers JL, Allen TC, et al. Conse…
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psnet.ahrq.gov/node/60897/psn-pdf
January 01, 2022 - Association between surgeon technical skills and patient
outcomes.
September 9, 2020
Stulberg JJ, Huang R, Kreutzer L, et al. Association Between Surgeon Technical Skills and Patient
Outcomes. JAMA Surg. 2022;157(3):219-220. doi:10.1001/jamasurg.2020.3007.
https://psnet.ahrq.gov/issue/association-between-surgeon-t…
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psnet.ahrq.gov/node/46524/psn-pdf
October 18, 2017 - Pressure Injury Prevention in Hospitals Training Program.
October 18, 2017
Rockville, MD: Agency for Healthcare Research and Quality; September 2017.
https://psnet.ahrq.gov/issue/pressure-injury-prevention-hospitals-training-program
Pressure ulcers are a common hospital-acquired condition that can lead to patient h…
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psnet.ahrq.gov/node/44221/psn-pdf
September 27, 2016 - Reducing surgical errors: implementing a three-hinge
approach to success.
September 27, 2016
Landers R. Reducing surgical errors: implementing a three-hinge approach to success. AORN J.
2015;101(6):657-65. doi:10.1016/j.aorn.2015.04.013.
https://psnet.ahrq.gov/issue/reducing-surgical-errors-implementing-three-hing…
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psnet.ahrq.gov/node/46438/psn-pdf
September 20, 2017 - Communicating Clearly About Medicines: Proceedings of
a Workshop.
September 20, 2017
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies
Press: 2017. ISBN: 9780309461856.
https://psnet.ahrq.gov/issue/communicating-clearly-about-medicines-proceedings-workshop
Patient h…
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psnet.ahrq.gov/node/47373/psn-pdf
November 14, 2018 - Blame: what does it look like?
November 14, 2018
Duthie EA. Blame: What does it look like? Nurs Manage. 2018;49(11):18-21.
doi:10.1097/01.NUMA.0000547256.76967.9e.
https://psnet.ahrq.gov/issue/blame-what-does-it-look
A just culture balances organizational context with appropriate accountability after an error. Thi…
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psnet.ahrq.gov/node/61003/psn-pdf
October 07, 2020 - Making Complaints Count: Supporting Complaints
Handling in the NHS and UK Government Departments.
October 7, 2020
Manchester, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN
9781528620666.
https://psnet.ahrq.gov/issue/making-complaints-count-supporting-complaints-handling-nhs-and-uk-
gover…
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psnet.ahrq.gov/node/37754/psn-pdf
May 14, 2008 - Potentially inappropriate medication use in hospitalized
elders.
May 14, 2008
Rothberg MB, Pekow PS, Liu F, et al. Potentially inappropriate medication use in hospitalized elders. J
Hosp Med. 2008;3(2):91-102. doi:10.1002/jhm.290.
https://psnet.ahrq.gov/issue/potentially-inappropriate-medication-use-hospitalized-e…
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psnet.ahrq.gov/node/42872/psn-pdf
December 30, 2014 - Errors in after-hours phone consultations: a simulation
study.
December 30, 2014
Joffe E, Turley JP, Hwang KO, et al. Errors in after-hours phone consultations: a simulation study. BMJ
Qual Saf. 2014;23(5):398-405. doi:10.1136/bmjqs-2013-002243.
https://psnet.ahrq.gov/issue/errors-after-hours-phone-consultations-s…
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psnet.ahrq.gov/node/47933/psn-pdf
August 07, 2019 - Just culture: it's more than policy.
August 7, 2019
Paradiso L, Sweeney N. Just culture: It's more than policy. Nurs Manage. 2019;50(6):38-45.
doi:10.1097/01.NUMA.0000558482.07815.ae.
https://psnet.ahrq.gov/issue/just-culture-its-more-policy
This survey study examined the relationship between just culture—a cultur…
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psnet.ahrq.gov/node/35383/psn-pdf
January 02, 2017 - North Mississippi Medical Center: a focus on quality,
safety, and financial critical success factors.
January 2, 2017
Murphree J, Englert J, Koch K, et al. North Mississippi Medical Center: a focus on quality, safety, and
financial critical success factors. Jt Comm J Qual Patient Saf. 2005;31(10):545-53.
https://p…
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psnet.ahrq.gov/node/34086/psn-pdf
May 27, 2011 - Overcoming barriers to adopting and implementing
computerized physician order entry systems in U.S.
hospitals.
May 27, 2011
Poon EG, Blumenthal D, Jaggi T, et al. Overcoming barriers to adopting and implementing computerized
physician order entry systems in U.S. hospitals. Health Aff (Millwood). 2004;23(4):184-90.…
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psnet.ahrq.gov/node/33934/psn-pdf
March 02, 2011 - A hospitalization from hell: a patient's perspective on
quality.
March 2, 2011
Cleary PD. A hospitalization from hell: a patient's perspective on quality. Ann Intern Med. 2003;138(1):33-
39.
https://psnet.ahrq.gov/issue/hospitalization-hell-patients-perspective-quality
The author shares the unique perspectives of…
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psnet.ahrq.gov/node/46023/psn-pdf
May 03, 2017 - Patient safety and leadership: do you walk the walk?
May 3, 2017
Jarrett MP. Patient Safety and Leadership: Do You Walk the Walk? J Healthc Manag. 2017;62(2):88-92.
doi:10.1097/JHM-D-17-00005.
https://psnet.ahrq.gov/issue/patient-safety-and-leadership-do-you-walk-walk
Hospital leaders are increasingly encouraged t…
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psnet.ahrq.gov/node/38942/psn-pdf
November 25, 2009 - Using in situ simulation to identify and resolve latent
environmental threats to patient safety: case study
involving a labor and delivery ward.
November 25, 2009
Hamman WR, Beaudin-Seiler BM, Beaubien JM, et al. Using in situ simulation to identify and resolve latent
environmental threats to patient safety: case …
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psnet.ahrq.gov/node/38312/psn-pdf
March 09, 2010 - Which aspects of safety culture predict incident reporting
behavior in neonatal intensive care units? A multilevel
analysis.
March 9, 2010
Snijders C, Kollen BJ, van Lingen RA, et al. Which aspects of safety culture predict incident reporting
behavior in neonatal intensive care units? A multilevel analysis. Crit C…
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psnet.ahrq.gov/node/38511/psn-pdf
March 25, 2009 - The High Costs of Weak Compliance With the New York
State Hospital Adverse Event Reporting and Tracking
System.
March 25, 2009
Thompson WC Jr. New York, NY: Office of the New York City Comptroller, Office of Policy Management;
2009.
https://psnet.ahrq.gov/issue/high-costs-weak-compliance-new-york-state-hospital-a…
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psnet.ahrq.gov/node/42022/psn-pdf
February 13, 2013 - Improving patient safety using the sterile cockpit
principle during medication administration: a
collaborative, unit-based project.
February 13, 2013
Fore AM, Sculli GL, Albee D, et al. Improving patient safety using the sterile cockpit principle during
medication administration: a collaborative, unit-based projec…