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psnet.ahrq.gov/node/46943/psn-pdf
November 16, 2018 - A piece of my mind. The art of constructive worrying.
November 16, 2018
John CC. The Art of Constructive Worrying. JAMA. 2018;319(22):2273-2274. doi:10.1001/jama.2018.6670.
https://psnet.ahrq.gov/issue/piece-my-mind-art-constructive-worrying
Both organizational culture and individual accountability are key to admit…
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psnet.ahrq.gov/node/43763/psn-pdf
April 22, 2015 - The nurse's role in medication safety.
April 22, 2015
Durham B. The nurse's role in medication safety. Nursing (Brux). 2015;45(4).
doi:10.1097/01.NURSE.0000461850.24153.8b.
https://psnet.ahrq.gov/issue/nurses-role-medication-safety-0
Nurses perform a critical role in preventing medication errors. This commentary e…
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psnet.ahrq.gov/node/38081/psn-pdf
September 24, 2008 - Making patients safer: nurses' responses to patient safety
alerts.
September 24, 2008
Lankshear A, Lowson K, Harden J, et al. Making patients safer: nurses’ responses to patient safety alerts. J
Adv Nurs. 2008;63(6). doi:10.1111/j.1365-2648.2008.04741.x.
https://psnet.ahrq.gov/issue/making-patients-safer-nurses-re…
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psnet.ahrq.gov/node/60163/psn-pdf
March 25, 2020 - Broken, fragmented health-care system failed daughter
who died by suicide.
March 25, 2020
Klowak M. CBC News. March 9, 2020.
https://psnet.ahrq.gov/issue/broken-fragmented-health-care-system-failed-daughter-who-died-suicide
System weaknesses are often at the root of never events. This news story discusses the suic…
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psnet.ahrq.gov/node/47244/psn-pdf
August 01, 2018 - The Second Society for Simulation in Healthcare
Research Summit: Beyond Our Boundaries.
August 1, 2018
Simul Healthc. 2018;13(3S suppl 1):S1-S55.
https://psnet.ahrq.gov/issue/second-society-simulation-healthcare-research-summit-beyond-our-boundaries
Simulation strategies can help examine team interaction and care …
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psnet.ahrq.gov/node/47412/psn-pdf
October 31, 2018 - The systems approach at the sharp end.
October 31, 2018
Cross SRH. The systems approach at the sharp end. Future Healthc J. 2019;5(3):176-180.
doi:10.7861/futurehosp.5-3-176.
https://psnet.ahrq.gov/issue/systems-approach-sharp-end
Systems solutions are often focused on creating improvements at the organizational o…
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psnet.ahrq.gov/node/44854/psn-pdf
March 16, 2016 - Bring back the autopsy.
March 16, 2016
Jauhar S. New York Times. March 3, 2016.
https://psnet.ahrq.gov/issue/bring-back-autopsy
Performance of autopsies, previously considered an essential learning tool for clinicians, has decreased in
recent years due to insufficient funding to cover costs and lack of physician e…
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psnet.ahrq.gov/node/50625/psn-pdf
November 06, 2019 - Pediatric medication safety considerations for
pharmacists in an adult hospital setting.
November 6, 2019
Kennedy AR, Massey LR. Pediatric medication safety considerations for pharmacists in an adult hospital
setting. Am J Health Syst Pharm. 2019;76(19):1481-1491. doi:10.1093/ajhp/zxz168.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/42856/psn-pdf
January 07, 2015 - Clinical benefits of electronic health record use: national
findings.
January 7, 2015
King J, Patel V, Jamoom EW, et al. Clinical benefits of electronic health record use: national findings.
Health Serv Res. 2014;49(1 Pt 2):392-404. doi:10.1111/1475-6773.12135.
https://psnet.ahrq.gov/issue/clinical-benefits-electr…
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psnet.ahrq.gov/node/45551/psn-pdf
November 30, 2016 - Parents' perspectives on "keeping their children safe" in
the hospital.
November 30, 2016
Rosenberg RE, Rosenfeld P, Williams E, et al. Parents' Perspectives on "Keeping Their Children Safe" in
the Hospital. J Nurs Care Qual. 2016;31(4):318-326. doi:10.1097/NCQ.0000000000000193.
https://psnet.ahrq.gov/issue/parent…
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psnet.ahrq.gov/node/41791/psn-pdf
December 04, 2016 - Managing the after effects of serious patient safety
incidents in the NHS: an online survey study.
December 4, 2016
Pinto A, Faiz O, Vincent CA. Managing the after effects of serious patient safety incidents in the NHS: an
online survey study. BMJ Qual Saf. 2012;21(12):1001-8. doi:10.1136/bmjqs-2012-000826.
https:…
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psnet.ahrq.gov/node/45236/psn-pdf
June 15, 2016 - Advancing Patient Safety in Cataract Surgery: A Betsy
Lehman Center Expert Panel Report.
June 15, 2016
Boston, MA: Betsy Lehman Center for Patient Safety and Medical Error Reduction; 2016.
https://psnet.ahrq.gov/issue/advancing-patient-safety-cataract-surgery-betsy-lehman-center-expert-panel-
report
Cataract surg…
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psnet.ahrq.gov/node/43421/psn-pdf
August 13, 2014 - The inevitability of physician burnout: implications for
interventions.
August 13, 2014
Montgomery A. The inevitability of physician burnout: Implications for interventions. Burn Res. 2014;1(1).
doi:10.1016/j.burn.2014.04.002.
https://psnet.ahrq.gov/issue/inevitability-physician-burnout-implications-interventions
…
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psnet.ahrq.gov/node/33953/psn-pdf
February 05, 2018 - Evidence-based Recommendations for Best Practices in
Weight Loss Surgery.
February 5, 2018
Expert Panel on Weight Loss Surgery, Betsy Lehman Center for Patient Safety and Medical Error
Reduction. Obesity Res. 2005;13(2):203-379.
https://psnet.ahrq.gov/issue/expert-panel-weight-loss-surgery-betsy-lehman-center-pat…
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psnet.ahrq.gov/node/851059/psn-pdf
June 28, 2023 - Causes for medical errors in obstetrics and gynaecology.
June 28, 2023
Klemann D, Rijkx M, Mertens H, et al. Causes for medical errors in obstetrics and gynaecology. Healthcare
(Basel). 2023;11(11):1636. doi:10.3390/healthcare11111636.
https://psnet.ahrq.gov/issue/causes-medical-errors-obstetrics-and-gynaecology
R…
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psnet.ahrq.gov/node/43069/psn-pdf
April 16, 2014 - Decimal numbers and safe interpretation of clinical
pathology results.
April 16, 2014
Sinnott M, Eley R, Steinle V, et al. Decimal numbers and safe interpretation of clinical pathology results. J
Clin Pathol. 2014;67(2):179-81. doi:10.1136/jclinpath-2013-201865.
https://psnet.ahrq.gov/issue/decimal-numbers-and-saf…
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psnet.ahrq.gov/node/44998/psn-pdf
April 20, 2016 - High reliability: excellent care every time.
April 20, 2016
Saver C. High reliability: Excellent care every time. OR manager. 2016;32(3):22-6.
https://psnet.ahrq.gov/issue/high-reliability-excellent-care-every-time
Achieving high reliability has attracted attention as a goal in health care. This article provides an…
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psnet.ahrq.gov/node/44733/psn-pdf
December 07, 2018 - Patient Safety in Ambulatory Settings: Technical Brief.
December 7, 2018
Evidence-based Practice Center. Rockville, MD: Agency for Healthcare Research and Quality; October 19,
2016.
https://psnet.ahrq.gov/issue/patient-safety-ambulatory-settings-technical-brief
The primary focus on patient safety research has been…
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psnet.ahrq.gov/node/60976/psn-pdf
September 30, 2020 - Dangerous wrong-route errors with tranexamic acid.
September 30, 2020
National Alert Network for Serious Medication Errors. Bethesda, MD: American Society of Health-System
Pharmacists and Institute for Safe Medication Practices. National Alert Network. September 9, 2020.
https://psnet.ahrq.gov/issue/dangerous-wrong…
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psnet.ahrq.gov/node/44931/psn-pdf
February 24, 2016 - The doctor's new dilemma.
February 24, 2016
Koven S. The Doctor's New Dilemma. N Engl J Med. 2016;374(7):608-9. doi:10.1056/NEJMp1513708.
https://psnet.ahrq.gov/issue/doctors-new-dilemma
Time pressures in the care delivery process can hinder clinicians' ability to connect with patients as
individuals. This comment…