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psnet.ahrq.gov/node/837859/psn-pdf
August 17, 2022 - The barriers and enhancers to trust in a just culture in
hospital settings: a systematic review.
August 17, 2022
van Marum S, Verhoeven D, de Rooy D. The barriers and enhancers to trust in a just culture in hospital
settings: a systematic review. J Patient Saf. 2022;18(7):e1067-e1075. doi:10.1097/pts.00000000000010…
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psnet.ahrq.gov/node/853064/psn-pdf
August 30, 2023 - Barriers and facilitators to implementing interventions for
reducing avoidable hospital readmission: systematic
review of qualitative studies.
August 30, 2023
Fu BQ, Zhong CCW, Wong CHL, et al. Barriers and facilitators to implementing interventions for reducing
avoidable hospital readmission: systematic review of…
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psnet.ahrq.gov/issue/drug-errors-are-dangerous-preventable
March 27, 2024 - Newspaper/Magazine Article
Drug errors are dangerous but preventable.
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September 8, 2010
This newspaper article describes steps p…
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psnet.ahrq.gov/node/37960/psn-pdf
September 24, 2010 - A survey of the impact of disruptive behaviors and
communication defects on patient safety.
September 24, 2010
Rosenstein AH, O'Daniel M. A survey of the impact of disruptive behaviors and communication defects on
patient safety. Jt Comm J Qual Patient Saf. 2008;34(8):464-471.
https://psnet.ahrq.gov/issue/survey-i…
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psnet.ahrq.gov/node/47883/psn-pdf
May 29, 2019 - Patient Safety in Obstetrics and Gynecology.
May 29, 2019
Gluck PA, ed. Obstet Gynecol Clin North Am. 2019;46:H1-H8, 199-398.
https://psnet.ahrq.gov/issue/patient-safety-obstetrics-and-gynecology
Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. Articles in
this speci…
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psnet.ahrq.gov/node/47902/psn-pdf
April 24, 2019 - Recommendations from a national panel on quality
improvement in obstetrics.
April 24, 2019
Lefebvre G, Calder LA, De Gorter R, et al. Recommendations From a National Panel on Quality
Improvement in Obstetrics. J Obstet Gynaecol Can. 2019;41(5):653-659. doi:10.1016/j.jogc.2019.02.011.
https://psnet.ahrq.gov/issue/r…
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psnet.ahrq.gov/node/74080/psn-pdf
January 01, 2022 - The nature of reported safety events related to care
coordination in the operating room setting in a tertiary
academic center.
November 17, 2021
Krishnan S, Wheeler KK, Pimentel MP, et al. The nature of reported safety events related to care
coordination in the operating room setting in a tertiary academic center.…
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psnet.ahrq.gov/node/46044/psn-pdf
December 21, 2017 - Addressing the opioid epidemic in the United States:
lessons from the Department of Veterans Affairs.
December 21, 2017
Gellad WF, Good CB, Shulkin DJ. Addressing the Opioid Epidemic in the United States: Lessons From the
Department of Veterans Affairs. AMA Intern Med. 2017;177(5):611-612.
doi:10.1001/jamainternme…
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psnet.ahrq.gov/node/45577/psn-pdf
February 08, 2017 - EHR-related medication errors in two ICUs.
February 8, 2017
Carayon P, Du S, Brown RL, et al. EHR-related medication errors in two ICUs. J Healthc Risk Manag.
2017;36(3):6-15. doi:10.1002/jhrm.21259.
https://psnet.ahrq.gov/issue/ehr-related-medication-errors-two-icus
Despite the demonstrated success of technology …
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psnet.ahrq.gov/node/47754/psn-pdf
April 17, 2019 - FDA identifies harm reported from sudden
discontinuation of opioid pain medicines and requires
label changes to guide prescribers on gradual,
individualized tapering.
April 17, 2019
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
https://psnet.ahrq.gov/issue/fda-identifies-harm-reported-sudden-…
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psnet.ahrq.gov/node/866860/psn-pdf
October 02, 2024 - Motivation for patient engagement in patient safety: a
multi-perspective, explorative survey.
October 2, 2024
Raab C, Gambashidze N, Brust L, et al. Motivation for patient engagement in patient safety: a multi-
perspective, explorative survey. BMC Health Serv Res. 2024;24(1):1052. doi:10.1186/s12913-024-11495-
x.
…
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psnet.ahrq.gov/node/47637/psn-pdf
January 16, 2019 - Case-based simulation empowering pediatric residents to
communicate about diagnostic uncertainty.
January 16, 2019
Olson ME, Borman-Shoap E, Mathias K, et al. Case-based simulation empowering pediatric residents to
communicate about diagnostic uncertainty. Diagnosis (Berl). 2018;5(4):243-248. doi:10.1515/dx-2018-
…
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psnet.ahrq.gov/node/46335/psn-pdf
December 19, 2017 - Prescription opioid analgesics commonly unused after
surgery: a systematic review.
December 19, 2017
Bicket MC, Long JJ, Pronovost PJ, et al. Prescription Opioid Analgesics Commonly Unused After Surgery.
JAMA Surg. 2017;152(11):1066-1071. doi:10.1001/jamasurg.2017.0831.
https://psnet.ahrq.gov/issue/prescription-op…
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psnet.ahrq.gov/node/840171/psn-pdf
November 16, 2022 - Critical care resource nurse team: a patient safety and
quality outcomes model.
November 16, 2022
https://psnet.ahrq.gov/innovation/critical-care-resource-nurse-team-patient-safety-and-quality-outcomes-
model
Rapid response teams (RRTs) are intended to improve timely identification and management of clinically
de…
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psnet.ahrq.gov/node/35670/psn-pdf
June 28, 2010 - Quality improvement implementation and hospital
performance on patient safety indicators.
June 28, 2010
Weiner BJ, Alexander JA, Baker LC, et al. Quality improvement implementation and hospital performance
on patient safety indicators. Med Care Res Rev. 2006;63(1):29-57.
https://psnet.ahrq.gov/issue/quality-improv…
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psnet.ahrq.gov/node/34666/psn-pdf
December 22, 2009 - Error reduction and performance improvement in the
emergency department through formal teamwork training:
evaluation results of the MedTeams project.
December 22, 2009
Morey JC, Simon R, Jay G, et al. Error reduction and performance improvement in the emergency
department through formal teamwork training: evaluati…
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psnet.ahrq.gov/node/836823/psn-pdf
March 30, 2022 - Five-year audit of adherence to an anaesthesia pre-
induction checklist.
March 30, 2022
Fuchs A, Frick S, Huber M, et al. Five?year audit of adherence to an anaesthesia pre?induction checklist.
Anaesthesia. 2022;77(7):751-762. doi:10.1111/anae.15704.
https://psnet.ahrq.gov/issue/five-year-audit-adherence-anaesthes…
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psnet.ahrq.gov/node/46775/psn-pdf
March 07, 2018 - Ten ERs in Colorado tried to curtail opioids and did better
than expected.
March 7, 2018
Daley J. Colorado Public Radio. February 23, 2018.
https://psnet.ahrq.gov/issue/ten-ers-colorado-tried-curtail-opioids-and-did-better-expected
Innovations in the prescribing of opioids in the emergency department are needed to…
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psnet.ahrq.gov/node/73915/psn-pdf
October 06, 2021 - Responses of physicians to an objective safety and
quality knowledge test: a cross-sectional study.
October 6, 2021
Burke HB, King HB. Responses of physicians to an objective safety and quality knowledge test: a cross-
sectional study. BMJ Open. 2021;11(9):e040779. doi:10.1136/bmjopen-2020-040779.
https://psnet.ah…
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psnet.ahrq.gov/node/843460/psn-pdf
February 01, 2023 - Persisting high rates of omissions during anesthesia
induction are decreased by utilization of a pre- & post-
induction checklist.
February 1, 2023
Krombach JW, Zürcher C, Simon SG, et al. Persisting high rates of omissions during anesthesia induction
are decreased by utilization of a pre- & post-induction checkli…