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psnet.ahrq.gov/node/41024/psn-pdf
December 21, 2011 - Teamwork and team training in the ICU: where do the
similarities with aviation end?
December 21, 2011
Reader TW, Cuthbertson BH. Teamwork and team training in the ICU: Where do the similarities with
aviation end? Crit Care. 2011;15(6). doi:10.1186/cc10353.
https://psnet.ahrq.gov/issue/teamwork-and-team-training-ic…
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psnet.ahrq.gov/node/50606/psn-pdf
October 30, 2019 - One doctor. 25 deaths. How could it have happened?
October 30, 2019
Healy J, Farr I, Feiger L, Duffy C. New York Times. October 11, 2019.
https://psnet.ahrq.gov/issue/one-doctor-25-deaths-how-could-it-have-happened
Systemic failures persistently undermine processes meant to keep patients safe. This news story discu…
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psnet.ahrq.gov/node/44526/psn-pdf
October 07, 2015 - The evolution of a safety culture.
October 7, 2015
Patton BS, Donovan KJ. The Evolution of a Safety Culture. Air Med J. 2015;34(5):264-8.
doi:10.1016/j.amj.2015.05.012.
https://psnet.ahrq.gov/issue/evolution-safety-culture
This commentary describes how an air transport unit at one hospital developed a safety cultu…
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psnet.ahrq.gov/node/41856/psn-pdf
November 21, 2012 - Electronic health records and National Patient-Safety
Goals.
November 21, 2012
Sittig DF, Singh H. Electronic Health Records and National Patient-Safety Goals. New England Journal of
Medicine. 2012;367(19). doi:10.1056/nejmsb1205420.
https://psnet.ahrq.gov/issue/electronic-health-records-and-national-patient-safet…
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psnet.ahrq.gov/node/73572/psn-pdf
August 04, 2021 - Center for Innovations in Quality, Effectiveness and
Safety. IQuESt!
August 4, 2021
Houston, TX: Baylor College of Medicine.
https://psnet.ahrq.gov/issue/center-innovations-quality-effectiveness-and-safety-iquest
This Center represents a partnership with the Veterans Affairs Health Services Research & Develo…
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psnet.ahrq.gov/node/39093/psn-pdf
November 11, 2009 - For whom the Bell Commission tolls: unintended effects
of limiting residents' hours.
November 11, 2009
Millard WB. For whom the bell commission tolls: unintended effects of limiting residents' hours. Ann Emerg
Med. 2009;54(4):A25-9.
https://psnet.ahrq.gov/issue/whom-bell-commission-tolls-unintended-effects-limitin…
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psnet.ahrq.gov/node/38982/psn-pdf
February 03, 2011 - Association of resident fatigue and distress with
perceived medical errors.
February 3, 2011
West CP, Tan AD, Habermann TM, et al. Association of resident fatigue and distress with perceived
medical errors. JAMA. 2009;302(12):1294-300. doi:10.1001/jama.2009.1389.
https://psnet.ahrq.gov/issue/association-resident-f…
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psnet.ahrq.gov/node/36042/psn-pdf
February 17, 2011 - Major congenital malformations after first-trimester
exposure to ACE inhibitors.
February 17, 2011
Cooper WO, Hernandez-Diaz S, Arbogast PG, et al. Major Congenital Malformations after First-Trimester
Exposure to ACE Inhibitors. New England Journal of Medicine. 2006;354(23). doi:10.1056/nejmoa055202.
https://psnet…
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psnet.ahrq.gov/node/837862/psn-pdf
August 17, 2022 - A California man’s ‘painful and terrifying’ road to a
Monkeypox diagnosis.
August 17, 2022
Fortiér J. Kaiser Health News. August 4, 2022.
https://psnet.ahrq.gov/issue/california-mans-painful-and-terrifying-road-monkeypox-diagnosis
Lack of familiarity with disease is known to contribute to missed and delayed diagno…
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psnet.ahrq.gov/node/37872/psn-pdf
January 11, 2017 - The effectiveness of root cause analysis: what does the
literature tell us?
January 11, 2017
Percarpio KB, Watts V, Weeks WB. The effectiveness of root cause analysis: what does the literature tell
us? Jt Comm J Qual Patient Saf. 2008;34(7):391-8.
https://psnet.ahrq.gov/issue/effectiveness-root-cause-analysis-what…
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psnet.ahrq.gov/node/34754/psn-pdf
February 06, 2018 - Patient Safety in Anesthetic Practice.
February 6, 2018
Morell RC; Eichhorn JH, eds. New York: Churchill Livingstone, 1997. ISBN: 9780443076824.
https://psnet.ahrq.gov/issue/patient-safety-anesthetic-practice
Anesthesiology made its mark early on in the quest for patient safety. Eichhorn was a part of the
converge…
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psnet.ahrq.gov/node/34618/psn-pdf
July 28, 2013 - National Survey on Consumers' Experiences With Patient
Safety and Quality Information.
July 28, 2013
Washington DC: Kaiser Family Foundation, Agency for Healthcare Research and Quality, Harvard School
of Public Health; 2004.
https://psnet.ahrq.gov/issue/national-survey-consumers-experiences-patient-safety-and-qual…
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psnet.ahrq.gov/node/35563/psn-pdf
June 08, 2010 - A comprehensive collaborative patient safety residency
curriculum to address the ACGME core competencies.
June 8, 2010
Singh R, Naughton B, Taylor JS, et al. A comprehensive collaborative patient safety residency curriculum
to address the ACGME core competencies. Med Educ. 2005;39(12):1195-204.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/44492/psn-pdf
September 23, 2015 - Teamwork in Healthcare.
September 23, 2015
Fam Syst Health. 2015;33(3):175-269.
https://psnet.ahrq.gov/issue/teamwork-healthcare
Teamwork is a key element of patient-centered care, but evidence regarding its use in the primary care
environment is limited. Articles in this special issue examine the reasons for this…
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psnet.ahrq.gov/node/44880/psn-pdf
September 06, 2016 - Drug shortages forcing hard decisions on rationing
treatments.
September 6, 2016
Fink S. New York Times. January 29, 2016.
https://psnet.ahrq.gov/issue/drug-shortages-forcing-hard-decisions-rationing-treatments
Drug shortages have become a routine challenge in medicine. Reporting on the impact of medication
short…
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psnet.ahrq.gov/node/36882/psn-pdf
February 24, 2011 - Resident perceptions of the impact of work hour
limitations.
February 24, 2011
Lin GA, Beck DC, Stewart AL, et al. Resident perceptions of the impact of work hour limitations. J Gen
Intern Med. 2007;22(7):969-75.
https://psnet.ahrq.gov/issue/resident-perceptions-impact-work-hour-limitations
The investigators surv…
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psnet.ahrq.gov/node/36610/psn-pdf
January 14, 2011 - Prevent medication errors: a New Year's resolution:
teaching patients about their medications.
January 14, 2011
Polzien G. Prevent medication errors: A New Year's resolution: teaching patients about their medications.
Home Healthc Nurse. 2007;25(1):59-62.
https://psnet.ahrq.gov/issue/prevent-medication-errors-new-…
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psnet.ahrq.gov/node/42025/psn-pdf
February 06, 2013 - Medical malpractice: why is it so hard for doctors to
apologize?
February 6, 2013
Sanghavi D.
https://psnet.ahrq.gov/issue/medical-malpractice-why-it-so-hard-doctors-apologize
Discussing barriers to physician error disclosure, this article details how an apology-and-offer approach and
analyzing claims data can im…
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psnet.ahrq.gov/node/43411/psn-pdf
October 01, 2014 - Analysis of medication errors in simulated pediatric
resuscitation by residents.
October 1, 2014
Porter E, Barcega B, Kim TY. Analysis of medication errors in simulated pediatric resuscitation by
residents. West J Emerg Med. 2014;15(4):486-90. doi:10.5811/westjem.2014.2.17922.
https://psnet.ahrq.gov/issue/analysis…
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psnet.ahrq.gov/node/74733/psn-pdf
February 02, 2022 - Prep, Stop, Block.
February 2, 2022
RA-UK, the Faculty of Pain Medicine, RCoA Simulation and NHS Improvement
https://psnet.ahrq.gov/issue/prep-stop-block
Standardization is a common strategy for preventing practice deviations that can contribute to harm. This
tool outlines a three-step process for minimizing the o…