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psnet.ahrq.gov/node/33575/psn-pdf
March 15, 2025 - Patient Engagement and Safety
March 15, 2025
Patient Engagement and Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-engagement-and-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the pati…
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psnet.ahrq.gov/node/865532/psn-pdf
April 10, 2024 - Let us to the TWISST; Plan, Simulate, Study and Act.
April 10, 2024
Colman N, Hebbar KB. Let us to the TWISST; Plan, Simulate, Study and Act. Pediatr Qual Saf.
2023;8(4):e664. doi:10.1097/pq9.0000000000000664.
https://psnet.ahrq.gov/innovation/let-us-twisst-plan-simulate-study-and-act
In situ simulation can identi…
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psnet.ahrq.gov/node/43869/psn-pdf
November 03, 2015 - Clinical safety of England's national programme for IT: a
retrospective analysis of all reported safety events 2005
to 2011.
November 3, 2015
Magrabi F, Baker M, Sinha I, et al. Clinical safety of England's national programme for IT: a retrospective
analysis of all reported safety events 2005 to 2011. Int J Med In…
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psnet.ahrq.gov/node/40586/psn-pdf
March 21, 2017 - Adopting real-time surveillance dashboards as a
component of an enterprisewide medication safety
strategy.
March 21, 2017
Waitman LR, Phillips IE, McCoy AB, et al. Adopting real-time surveillance dashboards as a component of
an enterprisewide medication safety strategy. Jt Comm J Qual Patient Saf. 2011;37(7):326-3…
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psnet.ahrq.gov/node/42039/psn-pdf
December 31, 2014 - Enhancing patient safety and quality of care by improving
the usability of electronic health record systems:
recommendations from AMIA.
December 31, 2014
Middleton B, Bloomrosen M, Dente MA, et al. Enhancing patient safety and quality of care by improving the
usability of electronic health record systems: recommen…
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psnet.ahrq.gov/node/47531/psn-pdf
June 19, 2019 - Patient Safety.
June 19, 2019
Health Aff (Millwood). 2018;37(11):1723-1908.
https://psnet.ahrq.gov/issue/patient-safety-14
The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This
special issue of Health Affairs, published 20 years after that report, highlights achie…
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psnet.ahrq.gov/node/39045/psn-pdf
April 04, 2011 - Risks of complications by attending physicians after
performing nighttime procedures.
April 4, 2011
Rothschild JM. Risks of Complications by Attending Physicians After Performing Nighttime Procedures.
JAMA. 2009;302(14):1565-1572. doi:10.1001/jama.2009.1423.
https://psnet.ahrq.gov/issue/risks-complications-attendi…
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psnet.ahrq.gov/node/47610/psn-pdf
March 13, 2019 - Patient safety outcomes under flexible and standard
resident duty-hour rules.
March 13, 2019
Silber JH, Bellini LM, Shea JA, et al; iCOMPARE Research Group. N Engl J Med. 2019;380:905-914.
https://psnet.ahrq.gov/issue/patient-safety-outcomes-under-flexible-and-standard-resident-duty-hour-rules
Duty hour reform for…
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psnet.ahrq.gov/node/44522/psn-pdf
June 21, 2016 - Impact of an electronic alert notification system
embedded in radiologists' workflow on closed-loop
communication of critical results: a time series analysis.
June 21, 2016
Lacson R, O'Connor SD, Sahni A, et al. Impact of an electronic alert notification system embedded in
radiologists' workflow on closed-loop com…
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psnet.ahrq.gov/node/40221/psn-pdf
July 21, 2011 - The association between a prolonged stay in the
emergency department and adverse events in older
patients admitted to hospital: a retrospective cohort
study.
July 21, 2011
Ackroyd-Stolarz S, Guernsey R, Mackinnon NJ, et al. The association between a prolonged stay in the
emergency department and adverse events in…
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psnet.ahrq.gov/node/60248/psn-pdf
April 22, 2020 - Circumstances involved in unsupervised solid dose
medication exposures among young children.
April 22, 2020
Agarwal M, Lovegrove MC, Geller RJ, et al. Circumstances involved in unsupervised solid dose medication
exposures among young children. J Pediatr. 2020;219. doi:10.1016/j.jpeds.2019.12.027.
https://psnet.ahr…
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psnet.ahrq.gov/node/40565/psn-pdf
June 29, 2011 - National study on the frequency, types, causes, and
consequences of voluntarily reported emergency
department medication errors.
June 29, 2011
Pham JC, Story JL, Hicks RW, et al. National study on the frequency, types, causes, and consequences of
voluntarily reported emergency department medication errors. J Emerg…
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psnet.ahrq.gov/node/39215/psn-pdf
January 03, 2017 - Adverse drug events among hospitalized Medicare
patients: epidemiology and national estimates from a new
approach to surveillance.
January 3, 2017
Classen D, Jaser L, Budnitz DS. Adverse drug events among hospitalized Medicare patients: epidemiology
and national estimates from a new approach to surveillance. Jt Co…
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psnet.ahrq.gov/node/46829/psn-pdf
July 23, 2018 - Quality and variability of patient directions in electronic
prescriptions in the ambulatory care setting.
July 23, 2018
Yang Y, Ward-Charlerie S, Dhavle AA, et al. Quality and Variability of Patient Directions in Electronic
Prescriptions in the Ambulatory Care Setting. J Manag Care Spec Pharm. 2018;24(7):691-699.
…
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psnet.ahrq.gov/node/38116/psn-pdf
February 18, 2011 - Factors associated with intern fatigue.
February 18, 2011
Friesen LD, Vidyarthi A, Baron RB, et al. Factors associated with intern fatigue. J Gen Intern Med.
2008;23(12):1981-6. doi:10.1007/s11606-008-0798-3.
https://psnet.ahrq.gov/issue/factors-associated-intern-fatigue
Reducing duty hours for physicians in train…
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psnet.ahrq.gov/node/42298/psn-pdf
December 31, 2014 - Using statistical text classification to identify health
information technology incidents.
December 31, 2014
Chai KEK, Anthony S, Coiera E, et al. Using statistical text classification to identify health information
technology incidents. J Am Med Inform Assoc. 2013;20(5):980-5. doi:10.1136/amiajnl-2012-001409.
htt…
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psnet.ahrq.gov/node/39171/psn-pdf
February 10, 2015 - Patient safety at ten: unmistakable progress, troubling
gaps.
February 10, 2015
Wachter R. Patient safety at ten: unmistakable progress, troubling gaps. Health Aff (Millwood).
2010;29(1):165-173. doi:10.1377/hlthaff.2009.0785.
https://psnet.ahrq.gov/issue/patient-safety-ten-unmistakable-progress-troubling-gaps
Th…
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psnet.ahrq.gov/node/39674/psn-pdf
July 14, 2010 - The management of test results in primary care: does an
electronic medical record make a difference?
July 14, 2010
Elder NC, McEwen TR, Flach J, et al. The management of test results in primary care: does an electronic
medical record make a difference? Fam Med. 2010;42(5):327-33.
https://psnet.ahrq.gov/issue/manag…
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psnet.ahrq.gov/node/43652/psn-pdf
August 04, 2015 - Do clinicians know which of their patients have central
venous catheters?: A multicenter observational study.
August 4, 2015
Chopra V, Govindan S, Kuhn L, et al. Do clinicians know which of their patients have central venous
catheters?: a multicenter observational study. Ann Intern Med. 2014;161(8):562-7. doi:10.73…
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psnet.ahrq.gov/node/47261/psn-pdf
August 15, 2018 - The association between professional burnout and
engagement with patient safety culture and outcomes: a
systematic review.
August 15, 2018
Mossburg SE, Himmelfarb CD. The Association Between Professional Burnout and Engagement With
Patient Safety Culture and Outcomes: A Systematic Review. J Patient Saf. 2018;17(8)…