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psnet.ahrq.gov/node/866076/psn-pdf
June 05, 2024 - Locum doctor working and quality and safety: a
qualitative study in English primary and secondary care.
June 5, 2024
Ferguson J, Stringer G, Walshe K, et al. Locum doctor working and quality and safety: a qualitative study in
English primary and secondary care. BMJ Qual Saf. 2024;33(6):354-362. doi:10.1136/bmjqs-20…
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psnet.ahrq.gov/node/34849/psn-pdf
May 14, 2012 - The end of the beginning: patient safety five years after
'To Err Is Human.'
May 14, 2012
Wachter RM. The End Of The Beginning: Patient Safety Five Years After ‘To Err Is Human’. Health Aff.
2004;23(Suppl1). doi:10.1377/hlthaff.w4.534.
https://psnet.ahrq.gov/issue/end-beginning-patient-safety-five-years-after-err-…
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psnet.ahrq.gov/node/60593/psn-pdf
June 17, 2020 - Failure to follow medication changes made at hospital
discharge is associated with adverse events in 30 days.
June 17, 2020
Weir DL, Motulsky A, Abrahamowicz M, et al. Failure to follow medication changes made at hospital
discharge is associated with adverse events in 30 days. Health Serv Res. 2020;55(4):512-523.
…
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psnet.ahrq.gov/node/860726/psn-pdf
January 17, 2024 - Sustained decrease in latent safety threats through
regular interprofessional in situ simulation training of
neonatal emergencies.
January 17, 2024
Mileder LP, Schwaberger B, Baik-Schneditz N, et al. Sustained decrease in latent safety threats through
regular interprofessional in situ simulation training of neonat…
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psnet.ahrq.gov/node/34671/psn-pdf
June 15, 2011 - Confidential clinician-reported surveillance of adverse
events among medical inpatients.
June 15, 2011
Weingart SN, Ship AN, Aronson MD. Confidential clinician-reported surveillance of adverse events among
medical inpatients. J Gen Intern Med. 2003;15(7). doi:10.1046/j.1525-1497.2000.06269.x.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/867017/psn-pdf
October 23, 2024 - Clinicians' use of health information exchange
technologies for medication reconciliation in the U.S.
Department of Veterans Affairs: a qualitative analysis.
October 23, 2024
Snyder ME, Nguyen KA, Patel H, et al. Clinicians' use of health information exchange technologies for
medication reconciliation in the U.S. …
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psnet.ahrq.gov/node/839821/psn-pdf
November 09, 2022 - Cognitive biases encountered by physicians in the
emergency room.
November 9, 2022
Kunitomo K, Harada T, Watari T. Cognitive biases encountered by physicians in the emergency room.
BMC Emerg Med. 2022;22(1):148. doi:10.1186/s12873-022-00708-3.
https://psnet.ahrq.gov/issue/cognitive-biases-encountered-physicians-em…
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psnet.ahrq.gov/node/36867/psn-pdf
August 31, 2011 - Multidisciplinary approach to inpatient medication
reconciliation in an academic setting.
August 31, 2011
Varkey P, Cunningham J, O'Meara J, et al. Multidisciplinary approach to inpatient medication reconciliation
in an academic setting. Am J Health Syst Pharm. 2007;64(8):850-4.
https://psnet.ahrq.gov/issue/multid…
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psnet.ahrq.gov/node/72497/psn-pdf
November 25, 2020 - A multisite study of interprofessional teamwork and
collaboration on general medical services.
November 25, 2020
O'Leary KJ, Manojlovich M, Johnson JK, et al. A multisite study of interprofessional teamwork and
collaboration on general medical services. Jt Comm J Qual Patient Saf. 2020;46(12):667-672.
doi:10.1016/…
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psnet.ahrq.gov/node/45922/psn-pdf
April 19, 2017 - Two sides to every story: the Dual Perspectives Method
for examining interruptions in healthcare.
April 19, 2017
McCurdie T, Sanderson P, Aitken LM, et al. Two sides to every story: The Dual Perspectives Method for
examining interruptions in healthcare. Appl Ergon. 2017;58:102-109. doi:10.1016/j.apergo.2016.05.012.…
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psnet.ahrq.gov/node/72548/psn-pdf
January 01, 2021 - Better nurse staffing is associated with survival for Black
patients and diminishes racial disparities in survival after
in-hospital cardiac arrests.
December 9, 2020
Brooks Carthon M, Brom H, McHugh MD, et al. Better nurse staffing is associated with survival for black
patients and diminishes racial disparities i…
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psnet.ahrq.gov/node/45874/psn-pdf
February 22, 2017 - Ethics in the pediatric emergency department: when
mistakes happen: an approach to the process, evaluation,
and response to medical errors.
February 22, 2017
Dreisinger N, Zapolsky N. Ethics in the Pediatric Emergency Department: When Mistakes Happen: An
Approach to the Process, Evaluation, and Response to Medical…
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psnet.ahrq.gov/node/72743/psn-pdf
February 17, 2021 - Preventable medication harm across health care settings:
a systematic review and meta-analysis.
February 17, 2021
Hodkinson A, Tyler N, Ashcroft DM, et al. Preventable medication harm across health care settings: a
systematic review and meta-analysis. BMC Med. 2020;18(1):313. doi:10.1186/s12916-020-01774-9.
https:…
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psnet.ahrq.gov/node/60048/psn-pdf
March 18, 2020 - 'Immunising' physicians against availability bias in
diagnostic reasoning: a randomised controlled
experiment.
March 18, 2020
Mamede S, de Carvalho-Filho MA, de Faria RMD, et al. ‘Immunising’ physicians against availability bias in
diagnostic reasoning: a randomised controlled experiment. BMJ Qual Saf. 2020;29(7):…
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www.ahrq.gov/evidencenow/projects/heart-health/about/stories/in-action/cascades-east.html
March 01, 2021 - New Ideas Lead to Big Changes in Care
Like many small- and medium-sized practices, the team at Cascades East Family Medicine is always searching for ways to improve care. For Cascades East, this meant enrolling in EvidenceNOW, which connected them with a practice facilitator, Mr. Steven Brantley.
In their wor…
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psnet.ahrq.gov/node/39716/psn-pdf
August 09, 2013 - Patient handovers within the hospital: translating
knowledge from motor racing to healthcare.
August 9, 2013
Catchpole K, Sellers R, Goldman A, et al. Patient handovers within the hospital: translating knowledge from
motor racing to healthcare. Qual Saf Health Care. 2010;19(4):318-22. doi:10.1136/qshc.2009.026542.
…
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psnet.ahrq.gov/node/37891/psn-pdf
June 09, 2011 - Classifying and predicting errors of inpatient medication
reconciliation.
June 9, 2011
Pippins JR, Gandhi TK, Hamann C, et al. Classifying and predicting errors of inpatient medication
reconciliation. J Gen Intern Med. 2008;23(9):1414-22. doi:10.1007/s11606-008-0687-9.
https://psnet.ahrq.gov/issue/classifying-and-…
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psnet.ahrq.gov/node/35907/psn-pdf
October 03, 2017 - Transparent and open discussion of errors does not
increase malpractice risk in trauma patients.
October 3, 2017
Stewart RM, Corneille MG, Johnston J, et al. Transparent and open discussion of errors does not increase
malpractice risk in trauma patients. Ann Surg. 2006;243(5):645-9; discussion 649-51.
https://psne…
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psnet.ahrq.gov/node/42419/psn-pdf
July 17, 2013 - Health IT Patient Safety Action and Surveillance Plan.
July 17, 2013
Washington, DC: Office of the National Coordinator for Health Information Technology; July 2, 2013.
https://psnet.ahrq.gov/issue/health-it-patient-safety-action-and-surveillance-plan
This report from the Department of Health and Human Services (HH…
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psnet.ahrq.gov/node/44127/psn-pdf
September 28, 2017 - Overkill: An avalanche of unnecessary medical care is
harming patients physically and financially. What can we
do about it?
September 28, 2017
Gawande A. The New Yorker. May 2015
https://psnet.ahrq.gov/issue/overkill-avalanche-unnecessary-medical-care-harming-patients-physically-and-
financially-what
The overuse…