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psnet.ahrq.gov/node/39405/psn-pdf
March 31, 2010 - ED overcrowding is associated with an increased
frequency of medication errors.
March 31, 2010
Kulstad EB, Sikka R, Sweis RT, et al. ED overcrowding is associated with an increased frequency of
medication errors. Am J Emerg Med. 2010;28(3):304-309. doi:10.1016/j.ajem.2008.12.014.
https://psnet.ahrq.gov/issue/ed-ov…
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psnet.ahrq.gov/node/39193/psn-pdf
April 21, 2011 - Disclosing harmful mammography errors to patients.
April 21, 2011
Gallagher TH, Cook AJ, Brenner RJ, et al. Disclosing Harmful Mammography Errors to Patients. Radiology.
2009;253(2). doi:10.1148/radiol.2532082320.
https://psnet.ahrq.gov/issue/disclosing-harmful-mammography-errors-patients
Disclosing errors to pati…
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psnet.ahrq.gov/node/34714/psn-pdf
February 18, 2011 - Relation between malpractice claims and adverse events
due to negligence. Results of the Harvard Medical
Practice Study III.
February 18, 2011
Localio AR, Lawthers AG, Brennan TA, et al. Relation between Malpractice Claims and Adverse Events
Due to Negligence. New England Journal of Medicine. 2010;325(4). doi:10.1…
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psnet.ahrq.gov/node/60523/psn-pdf
May 27, 2020 - "We're not ready, but I don't think you're ever ready."
Clinician perspectives on implementation of crisis
standards of care.
May 27, 2020
Chuang E, Cuartas PA, Powell T, et al. "We're not ready, but I don't think you're ever ready." Clinician
perspectives on implementation of crisis standards of care. AJOB Empir …
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psnet.ahrq.gov/node/42474/psn-pdf
September 19, 2015 - A new, evidence-based estimate of patient harms
associated with hospital care.
September 19, 2015
James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf.
2013;9(3):122-128. doi:10.1097/PTS.0b013e3182948a69.
https://psnet.ahrq.gov/issue/new-evidence-based-estimate-pat…
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psnet.ahrq.gov/node/36150/psn-pdf
September 29, 2010 - Nurse-physician communication during labor and birth:
implications for patient safety.
September 29, 2010
Simpson KR, James DC, Knox E. Nurse-physician communication during labor and birth: implications for
patient safety. J Obstet Gynecol Neonatal Nurs. 2006;35(4):547-56.
https://psnet.ahrq.gov/issue/nurse-physic…
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psnet.ahrq.gov/node/41858/psn-pdf
November 21, 2012 - Disorganized care: the findings of an iterative, in-depth
analysis of surgical morbidity and mortality.
November 21, 2012
Anderson CI, Nelson CS, Graham CF, et al. Disorganized care: the findings of an iterative, in-depth
analysis of surgical morbidity and mortality. J Surg Res. 2012;177(1):43-8. doi:10.1016/j.jss.…
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psnet.ahrq.gov/node/72774/psn-pdf
February 24, 2021 - Preventable adverse drug events causing hospitalisation:
identifying root causes and developing a surveillance and
learning system at an urban community hospital, a cross-
sectional observational study.
February 24, 2021
de Lemos J, Loewen PS, Nagle C, et al. Preventable adverse drug events causing hospitalisation…
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psnet.ahrq.gov/node/849329/psn-pdf
May 24, 2023 - Interorganizational health information exchange-related
patient safety incidents: a descriptive register-based
qualitative study.
May 24, 2023
Hyvämäki P, Sneck S, Meriläinen M, et al. Interorganizational health information exchange-related patient
safety incidents: a descriptive register-based qualitative study. …
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psnet.ahrq.gov/node/42123/psn-pdf
June 18, 2013 - On higher ground: ethical reasoning and its relationship
with error disclosure.
June 18, 2013
Cole AP, Block L, Wu AW. On higher ground: ethical reasoning and its relationship with error disclosure.
BMJ Qual Saf. 2013;22(7):580-585. doi:10.1136/bmjqs-2012-001496.
https://psnet.ahrq.gov/issue/higher-ground-ethical-…
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psnet.ahrq.gov/node/35935/psn-pdf
June 16, 2011 - Operating room teamwork among physicians and nurses:
teamwork in the eye of the beholder.
June 16, 2011
Makary MA, Sexton B, Freischlag JA, et al. Operating room teamwork among physicians and nurses:
teamwork in the eye of the beholder. J Am Coll Surg. 2006;202(5):746-52.
https://psnet.ahrq.gov/issue/operating-roo…
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psnet.ahrq.gov/node/837311/psn-pdf
June 01, 2022 - Effects of healthcare organization actions and policies
related to COVID-19 on perceived organizational support
among U.S. internists: a national study.
June 1, 2022
Sonis J, Pathman DE, Read S, et al. Effects of healthcare organization actions and policies related to
COVID-19 on perceived organizational support a…
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psnet.ahrq.gov/node/840484/psn-pdf
November 30, 2022 - Interdisciplinary collaboration across secondary and
primary care to improve medication safety in the elderly
(The IMMENSE study) - a randomized controlled trial.
November 30, 2022
Johansen JS, Halvorsen KH, Svendsen K, et al. Interdisciplinary collaboration across secondary and
primary care to improve medication …
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psnet.ahrq.gov/node/866554/psn-pdf
August 21, 2024 - Multi-team shared expectations tool (MT-SET): an
exercise to improve teamwork across health care teams.
August 21, 2024
Marsteller JA, Rosen MA, Wyskiel R, et al. Multi-team shared expectations tool (MT-SET): an exercise to
improve teamwork across health care teams. Jt Comm J Qual Patient Saf. 2024;50(10):737-744.
…
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psnet.ahrq.gov/node/42047/psn-pdf
March 18, 2013 - Do you have to re-examine to reconsider your diagnosis?
Checklists and cardiac exam.
March 18, 2013
Sibbald M, de Bruin A, Cavalcanti RB, et al. Do you have to re-examine to reconsider your diagnosis?
Checklists and cardiac exam. BMJ Qual Saf. 2013;22(4):333-8. doi:10.1136/bmjqs-2012-001537.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/38673/psn-pdf
April 30, 2014 - New world of patient safety. 23rd Annual Samuel Jason
Mixter Lecture.
April 30, 2014
Leape L. New world of patient safety: 23rd Annual Samuel Jason Mixter lecture. Arch Surg.
2009;144(5):394-8. doi:10.1001/archsurg.2009.78.
https://psnet.ahrq.gov/issue/new-world-patient-safety-23rd-annual-samuel-jason-mixter-lectu…
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psnet.ahrq.gov/node/37271/psn-pdf
December 19, 2011 - Is hospital patient care becoming safer? A conversation
with Lucian Leape.
December 19, 2011
Leape L. Is hospital patient care becoming safer? A conversation with Lucian Leape. Interview by Peter I.
Buerhaus. Health Aff (Millwood). 2007;26(6):w687-96.
https://psnet.ahrq.gov/issue/hospital-patient-care-becoming-saf…
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psnet.ahrq.gov/node/46010/psn-pdf
July 12, 2017 - Changing the medical malpractice system to align with
what we know about patient safety and quality
improvement.
July 12, 2017
Sklar DP. Changing the Medical Malpractice System to Align With What We Know About Patient Safety
and Quality Improvement. Acad Med. 2017;92(7):891-894. doi:10.1097/ACM.0000000000001733.
…
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psnet.ahrq.gov/node/42113/psn-pdf
March 20, 2013 - Preventing in-facility pressure ulcers as a patient safety
strategy: a systematic review.
March 20, 2013
Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic
review. Ann Intern Med. 2013;158(5 Pt 2):410-416. doi:10.7326/0003-4819-158-5-201303051-00008.
https:/…
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psnet.ahrq.gov/node/47322/psn-pdf
September 12, 2018 - Crossing the Global Quality Chasm: Improving Health
Care Worldwide.
September 12, 2018
Committee on Improving the Quality of Health Care Globally. National Academies of Sciences,
Engineering, and Medicine. Washington DC: National Academies Press; August 2018. ISBN:
9780309483087.
https://psnet.ahrq.gov/issue/cros…