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psnet.ahrq.gov/node/37056/psn-pdf
February 24, 2011 - Use of multidisciplinary rounds to simultaneously
improve quality outcomes, enhance resident education,
and shorten length of stay.
February 24, 2011
O'Mahony S, Mazur E, Charney P, et al. Use of multidisciplinary rounds to simultaneously improve quality
outcomes, enhance resident education, and shorten length of …
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psnet.ahrq.gov/node/38326/psn-pdf
January 14, 2009 - Results of a medication reconciliation survey from the
2006 Society of Hospital Medicine national meeting.
January 14, 2009
Clay BJ, Halasyamani L, Stucky ER, et al. Results of a medication reconciliation survey from the 2006
Society of Hospital Medicine national meeting. J Hosp Med. 2008;3(6). doi:10.1002/jhm.370.…
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psnet.ahrq.gov/node/72608/psn-pdf
December 23, 2020 - Incidence of Adverse Events in Indian Health Service
Hospitals.
December 23, 2020
Office of the Inspector General: Washington DC; December 2020. OIG report OEI-06-17-00530.
https://psnet.ahrq.gov/issue/incidence-adverse-events-indian-health-service-hospitals
Challenges beset safe care delivery for indigenous …
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psnet.ahrq.gov/node/46326/psn-pdf
October 18, 2017 - Surgical Patient Safety: A Case-Based Approach.
October 18, 2017
Stahel PF, ed. New York, NY: McGraw-Hill Education/Medical; 2017. ISBN: 9780071842631.
https://psnet.ahrq.gov/issue/surgical-patient-safety-case-based-approach
Surgical residency can be a stressful learning experience. This textbook provides an introd…
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psnet.ahrq.gov/node/44074/psn-pdf
November 16, 2015 - Investigating Clinical Incidents in the NHS.
November 16, 2015
Sixth Report of Session 2014–15. House of Commons Public Administration Select Committee. London,
England: The Stationery Office; March 27, 2015. Publication HC 886.
https://psnet.ahrq.gov/issue/investigating-clinical-incidents-nhs
Applying evidence ge…
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psnet.ahrq.gov/node/38783/psn-pdf
September 02, 2009 - Medical negligence in drug associated deaths.
September 2, 2009
Madea B, Musshoff F, Preuss J. Medical negligence in drug associated deaths. Forensic Sci Int.
2009;190(1-3):67-73. doi:10.1016/j.forsciint.2009.05.014.
https://psnet.ahrq.gov/issue/medical-negligence-drug-associated-deaths
This study reports that acc…
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psnet.ahrq.gov/node/45557/psn-pdf
October 27, 2016 - Time-out: the professional and organizational ethics of
speaking up in the OR.
October 27, 2016
Berlinger N, Dietz E. Time-out: The Professional and Organizational Ethics of Speaking Up in the OR. AMA
J Ethics. 2016;18(9):925-32. doi:10.1001/journalofethics.2016.18.9.stas1-1609.
https://psnet.ahrq.gov/issue/time-o…
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psnet.ahrq.gov/node/44389/psn-pdf
August 19, 2015 - A method of addressing proprietary name similarity for
US prescription drugs.
August 19, 2015
Stockbridge MD, Taylor K. A Method of Addressing Proprietary Name Similarity for US Prescription Drugs.
Ther Innov Regul Sci. 2015;49(4). doi:10.1177/2168479015570331.
https://psnet.ahrq.gov/issue/method-addressing-propri…
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psnet.ahrq.gov/node/44327/psn-pdf
August 26, 2015 - Safely Home: What Happens When People Leave Hospital
Care Settings?
August 26, 2015
London, UK: Healthwatch England; July 2015.
https://psnet.ahrq.gov/issue/safely-home-what-happens-when-people-leave-hospital-care-settings
Discharges are vulnerable periods for patients, often due to miscommunication, delays, and l…
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psnet.ahrq.gov/node/73925/psn-pdf
January 01, 2022 - Patient safety and mental health-a growing quality gap in
Canada.
October 6, 2021
Waddell AE, Gratzer D. Patient safety and mental health-a growing quality gap in Canada. Can J
Psychiatry. 2022;67(4):246-249. doi:10.1177/07067437211036596.
https://psnet.ahrq.gov/issue/patient-safety-and-mental-health-growing-quali…
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psnet.ahrq.gov/node/46516/psn-pdf
December 16, 2017 - The business case for investing in physician well-being.
December 16, 2017
Shanafelt TD, Goh J, Sinsky CA. The Business Case for Investing in Physician Well-being. JAMA Intern
Med. 2017;177(12):1826-1832. doi:10.1001/jamainternmed.2017.4340.
https://psnet.ahrq.gov/issue/business-case-investing-physician-well-being
…
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psnet.ahrq.gov/node/47842/psn-pdf
April 10, 2019 - Learning From Invited Reviews.
April 10, 2019
London, UK: Royal College of Surgeons of England; 2019.
https://psnet.ahrq.gov/issue/learning-invited-reviews
Physical demands and technical complexities can affect surgical safety. This resource is designed to
capture frontline perceptions of surgeons in the United Ki…
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psnet.ahrq.gov/node/38938/psn-pdf
July 26, 2023 - ISMP's List of Confused Drug Names.
July 26, 2023
Horsham, PA; Institute for Safe Medication Practices: July 2023.
https://psnet.ahrq.gov/issue/ismps-list-confused-drug-names
Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet
provides a comprehensive list of commonly…
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psnet.ahrq.gov/node/37809/psn-pdf
November 21, 2016 - Partnering with Patients and Families to Design a Patient-
and Family-Centered Health Care System:
Recommendations and Promising Practices.
November 21, 2016
Johnson B, Abraham M, Conway J, et al. Bethesda, MD: Institute for Family-Centered Care; April 2008.
https://psnet.ahrq.gov/issue/partnering-patients-and-fam…
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psnet.ahrq.gov/node/47416/psn-pdf
January 09, 2019 - Supervision, autonomy, and medical error in the teaching
clinic.
January 9, 2019
Cossman JP, Wang M, Fischer AA. Supervision, autonomy, and medical error in the teaching clinic. J Am
Acad Dermatol. 2018;79(5):981-983. doi:10.1016/j.jaad.2017.12.033.
https://psnet.ahrq.gov/issue/supervision-autonomy-and-medical-err…
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psnet.ahrq.gov/node/60766/psn-pdf
August 05, 2020 - Dermatology faces a reckoning: lack of darker skin in
textbooks and journals harms care for patients of color.
August 5, 2020
McFarling UL. Stat. July 21, 2020.
https://psnet.ahrq.gov/issue/dermatology-faces-reckoning-lack-darker-skin-textbooks-and-journals-harms-
care-patients-color
Dermatologists rely on v…
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psnet.ahrq.gov/node/44175/psn-pdf
October 13, 2015 - Impact of crisis resource management simulation-based
training for interprofessional and interdisciplinary teams:
a systematic review.
October 13, 2015
Fung L, Boet S, Bould D, et al. Impact of crisis resource management simulation-based training for
interprofessional and interdisciplinary teams: A systematic revi…
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psnet.ahrq.gov/node/38976/psn-pdf
October 07, 2009 - Radiology errors: are we learning from our mistakes?
October 7, 2009
Mankad K, Hoey ETD, Jones JB, et al. Radiology errors: are we learning from our mistakes? Clin Radiol.
2009;64(10):988-93. doi:10.1016/j.crad.2009.06.002.
https://psnet.ahrq.gov/issue/radiology-errors-are-we-learning-our-mistakes
This survey stud…
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psnet.ahrq.gov/node/73496/psn-pdf
July 14, 2021 - Racism in pain medicine: we can and should do more.
July 14, 2021
Strand NH, Mariano ER, Goree JH, et al. Racism in pain medicine: we can and should do more. Mayo Clin
Proc. 2021;96(6):1394-1400. doi:10.1016/j.mayocp.2021.02.030.
https://psnet.ahrq.gov/issue/racism-pain-medicine-we-can-and-should-do-more
Systemic …
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psnet.ahrq.gov/node/42679/psn-pdf
October 23, 2013 - An evidence-based toolkit for the development of
effective and sustainable root cause analysis system
safety solutions.
October 23, 2013
Hettinger Z, Fairbanks RJ, Hegde S, et al. An evidence-based toolkit for the development of effective and
sustainable root cause analysis system safety solutions. J Healthc Risk …