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psnet.ahrq.gov/node/45179/psn-pdf
July 13, 2016 - Communication and shared understanding between
parents and resident-physicians at night.
July 13, 2016
Khan A, Rogers JE, Forster CS, et al. Communication and Shared Understanding Between Parents and
Resident-Physicians at Night. Hosp Pediatr. 2016;6(6):319-29. doi:10.1542/hpeds.2015-0224.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/50708/psn-pdf
December 04, 2019 - Identifying medication errors in neonatal intensive care
units: a two-center study
December 4, 2019
Eslami K, Aletayeb F, Aletayeb SMH, et al. Identifying medication errors in neonatal intensive care units: a
two-center study. BMC Pediatr. 2019;19(1):365. doi:10.1186/s12887-019-1748-4.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/865705/psn-pdf
May 01, 2024 - Healthcare team resilience during COVID-19: a qualitative
study.
May 1, 2024
Ambrose JW, Catchpole K, Evans HL, et al. Healthcare team resilience during COVID-19: a qualitative
study. BMC Health Serv Res. 2024;24(1):459. doi:10.1186/s12913-024-10895-3.
https://psnet.ahrq.gov/issue/healthcare-team-resilience-during…
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psnet.ahrq.gov/node/60600/psn-pdf
June 17, 2020 - Reasons for drug administration problems and perceived
needs for assistance of patients, family caregivers, and
nurses: a qualitative study.
June 17, 2020
Lampert A, Haefeli WE, Seidling HM. Reasons for drug administration problems and perceived needs for
assistance of patients, family caregivers, and nurses: a qu…
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psnet.ahrq.gov/node/865594/psn-pdf
January 01, 2025 - Understanding the informal aspects of medication
processes to maintain patient safety in hospitals: a
sociotechnical ethnographic study in paediatric units.
April 17, 2024
Sutherland AB, Phipps DL, Grant S, et al. Understanding the informal aspects of medication processes to
maintain patient safety in hospitals: a…
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psnet.ahrq.gov/node/60359/psn-pdf
May 20, 2020 - Incorrect use of smart infusion pump in the operating
room (OR) leads to milrinone overdose.
May 20, 2020
ISMP Medication Safety Alert! Acute care edition. May 7, 2020;25(9).
https://psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone-
overdose
Lack of familiarity with sm…
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psnet.ahrq.gov/node/73532/psn-pdf
July 28, 2021 - The standardisation of handoffs in a large academic
paediatric emergency department using I-PASS.
July 28, 2021
Chladek MS, Doughty C, Patel B, et al. The Standardisation of handoffs in a large academic paediatric
emergency department using I-PASS. BMJ Open Qual. 2021;10(3):e001254. doi:10.1136/bmjoq-2020-
001254.…
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psnet.ahrq.gov/node/60557/psn-pdf
January 01, 2021 - Implementing receiver-driven handoffs to the emergency
department to reduce miscommunication.
June 3, 2020
Huth K, Stack AM, Hatoun J, et al. Implementing receiver-driven handoffs to the emergency department to
reduce miscommunication. BMJ Qual Saf. 2021;30(3):208-215. doi:10.1136/bmjqs-2019-010540.
https://psnet.…
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psnet.ahrq.gov/node/46376/psn-pdf
December 07, 2017 - User-centered collaborative design and development of
an inpatient safety dashboard.
December 7, 2017
Mlaver E, Schnipper JL, Boxer RB, et al. User-Centered Collaborative Design and Development of an
Inpatient Safety Dashboard. Jt Comm J Qual Patient Saf. 2017;43(12):676-685.
doi:10.1016/j.jcjq.2017.05.010.
https…
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psnet.ahrq.gov/node/47186/psn-pdf
October 24, 2018 - Quality, Value, and Patient Safety in Orthopedic Surgery.
October 24, 2018
Azar FM, ed. Orthop Clin North Am. 2018;49(4):A1-A8,389-552.
https://psnet.ahrq.gov/issue/quality-value-and-patient-safety-orthopedic-surgery
Quality and value have intersecting influence on the safety of health care. Articles in this specia…
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psnet.ahrq.gov/node/44101/psn-pdf
November 06, 2015 - Association between exposure to nonactionable
physiologic monitor alarms and response time in a
children's hospital.
November 6, 2015
Bonafide CP, Lin R, Zander M, et al. Association between exposure to nonactionable physiologic monitor
alarms and response time in a children's hospital. J Hosp Med. 2015;10(6):345-…
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psnet.ahrq.gov/node/853975/psn-pdf
September 27, 2023 - Strategies for Improving Clinician Psychological Safety in
Reporting and Discussing Diagnostic Error.
September 27, 2023
Amin D, Cosby K. Rockville, MD: Agency for Healthcare Research and Quality; September 2023.
Publication No. 23-0040-6-EF.
https://psnet.ahrq.gov/issue/strategies-improving-clinician-psychologica…
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psnet.ahrq.gov/node/854826/psn-pdf
October 25, 2023 - Observing sources of system resilience using in situ
alarm simulations.
October 25, 2023
McLoone M, McNamara M, Jennings MA, et al. Observing sources of system resilience using in situ alarm
simulations. J Hosp Med. 2023;18(11):994-998. doi:10.1002/jhm.13217.
https://psnet.ahrq.gov/issue/observing-sources-system-r…
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psnet.ahrq.gov/node/840489/psn-pdf
November 30, 2022 - A longitudinal study on the impact of simulation on
positive deviance through speaking up.
November 30, 2022
M. Violato E. A longitudinal study on the impact of simulation on positive deviance through speaking up.
Can J Respir Ther. 2022;58:137-142. doi:10.29390/cjrt-2022-006.
https://psnet.ahrq.gov/issue/longitud…
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psnet.ahrq.gov/node/46982/psn-pdf
June 13, 2018 - Advances in perioperative quality and safety.
June 13, 2018
Anderson KT, Appelbaum R, Bartz-Kurycki MA, et al. Advances in perioperative quality and safety. Semin
Pediatr Surg. 2018;27(2):92-101. doi:10.1053/j.sempedsurg.2018.02.006.
https://psnet.ahrq.gov/issue/advances-perioperative-quality-and-safety
Clinical s…
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psnet.ahrq.gov/node/42513/psn-pdf
January 15, 2014 - A comprehensive patient safety program can significantly
reduce preventable harm, associated costs, and hospital
mortality.
January 15, 2014
Brilli RJ, McClead RE, Crandall W, et al. A comprehensive patient safety program can significantly reduce
preventable harm, associated costs, and hospital mortality. J Pediat…
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psnet.ahrq.gov/node/866283/psn-pdf
July 10, 2024 - Safety and Quality of Parenteral Nutrition: Translating
Guidelines into Clinical Practice Considering Different
Organizational Settings.
July 10, 2024
Am J Health Syst Pharm. 2024;81(supp 3):s73-s136.
https://psnet.ahrq.gov/issue/safety-and-quality-parenteral-nutrition-translating-guidelines-clinical-practice-
co…
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psnet.ahrq.gov/node/46861/psn-pdf
February 28, 2018 - Special K with no license to kill: accidental ketamine
overdose on induction of general anesthesia.
February 28, 2018
Warner LL, Smischney N. Accidental Ketamine Overdose on Induction of General Anesthesia. Am J Case
Rep. 2018;19:10-12.
https://psnet.ahrq.gov/issue/special-k-no-license-kill-accidental-ketamine-ove…
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psnet.ahrq.gov/node/45816/psn-pdf
February 01, 2017 - Parent preferences for medical error disclosure: a
qualitative study.
February 1, 2017
Coffey M, Espin S, Hahmann T, et al. Parent Preferences for Medical Error Disclosure: A Qualitative Study.
Hosp Pediatr. 2017;7(1):24-30. doi:10.1542/hpeds.2016-0048.
https://psnet.ahrq.gov/issue/parent-preferences-medical-error…
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psnet.ahrq.gov/node/837060/psn-pdf
May 11, 2022 - Clinician distress and inappropriate antibiotic prescribing
for acute respiratory tract infections: a retrospective
cohort study.
May 11, 2022
Brady KJS, Barlam TF, Trockel MT, et al. Clinician distress and inappropriate antibiotic prescribing for
acute respiratory tract infections: a retrospective cohort study. J…