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psnet.ahrq.gov/node/44903/psn-pdf
September 27, 2016 - What would you ideally do if there were no targets? An
ethnographic study of the unintended consequences of
top-down governance in two clinical settings.
September 27, 2016
Allard J, Bleakley A. What would you ideally do if there were no targets? An ethnographic study of the
unintended consequences of top-down gov…
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psnet.ahrq.gov/node/45371/psn-pdf
April 24, 2017 - Patient safety and workplace bullying: an integrative
review.
April 24, 2017
Houck NM, Colbert AM. Patient Safety and Workplace Bullying: An Integrative Review. J Nurs Care Qual.
2017;32(2):164-171. doi:10.1097/NCQ.0000000000000209.
https://psnet.ahrq.gov/issue/patient-safety-and-workplace-bullying-integrative-rev…
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psnet.ahrq.gov/node/43093/psn-pdf
August 12, 2014 - Identifying systems failures in the pathway to a
catastrophic event: an analysis of national incident report
data relating to vinca alkaloids.
August 12, 2014
Franklin BD, Panesar S, Vincent CA, et al. Identifying systems failures in the pathway to a catastrophic
event: an analysis of national incident report data…
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psnet.ahrq.gov/node/44351/psn-pdf
October 21, 2015 - Heparin-containing medical devices and combination
products: recommendations for labeling and safety
testing. Draft guidance for industry and Food and Drug
Administration staff.
October 21, 2015
Federal Register. Washington, DC: US Department of Health and Human Services. Baltimore, MD: Food
and Drug Administrati…
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psnet.ahrq.gov/node/45573/psn-pdf
November 16, 2016 - High reliability of care in orthopedic surgery: are we there
yet?
November 16, 2016
Anoushiravani AA, Sayeed Z, El-Othmani MM, et al. High Reliability of Care in Orthopedic Surgery: Are We
There Yet? Orthop Clin North Am. 2016;47(4):689-95. doi:10.1016/j.ocl.2016.05.011.
https://psnet.ahrq.gov/issue/high-reliabili…
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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/44253/psn-pdf
August 24, 2015 - Acceptability and feasibility of the Leapfrog computerized
physician order entry evaluation tool for hospitals outside
the United States.
August 24, 2015
Cho IS, Lee J-H, Choi S-K, et al. Acceptability and feasibility of the Leapfrog computerized physician order
entry evaluation tool for hospitals outside the Unit…
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psnet.ahrq.gov/node/44607/psn-pdf
August 19, 2016 - Underlying risk factors for prescribing errors in long-term
aged care: a qualitative study.
August 19, 2016
Tariq A, Georgiou A, Raban MZ, et al. Underlying risk factors for prescribing errors in long-term aged care:
a qualitative study. BMJ Qual Saf. 2016;25(9):704-15. doi:10.1136/bmjqs-2015-004589.
https://psnet…
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psnet.ahrq.gov/node/844774/psn-pdf
September 11, 2019 - Advances in Human Factors and Ergonomics in
Healthcare and Medical Devices.
September 11, 2019
Lightner NJ, Kalra J, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030204501.
https://psnet.ahrq.gov/issue/advances-human-factors-and-ergonomics-healthcare-and-medical-devices
Human-centered processes, techno…
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psnet.ahrq.gov/node/867046/psn-pdf
October 30, 2024 - The future of safety and quality in radiation oncology.
October 30, 2024
Talcott W, Covington E, Bazan J, et al. The future of safety and quality in radiation oncology. Semin Radiat
Oncol. 2024;34(4):433-440. doi:10.1016/j.semradonc.2024.07.008.
https://psnet.ahrq.gov/issue/future-safety-and-quality-radiation-oncol…
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psnet.ahrq.gov/node/45845/psn-pdf
December 19, 2017 - You can't blame the wreck on the train.
December 19, 2017
Potts JR. You can't blame the wreck on the train. Am J Surg. 2017;214(5):974-978.
doi:10.1016/j.amjsurg.2016.11.046.
https://psnet.ahrq.gov/issue/you-cant-blame-wreck-train
Insufficient supervision can limit resident education, which may increase risks to p…
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psnet.ahrq.gov/node/844768/psn-pdf
September 11, 2019 - Standardized orders for titrating vasopressors: do efforts
to improve safety slow delivery of care?
September 11, 2019
Baker DW, Campbell R. Standardized Orders for Titrating Vasopressors: Do Efforts to Improve Safety Slow
Delivery of Care? Jt Comm J Qual Patient Saf. 2019;45(9):589-590. doi:10.1016/j.jcjq.2019.07.…
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psnet.ahrq.gov/node/47747/psn-pdf
March 13, 2019 - A piece of my mind. Hard times and hard stops.
March 13, 2019
Lifflander AL. Hard Times and Hard Stops. JAMA. 2019;321(9):837-838. doi:10.1001/jama.2019.1208.
https://psnet.ahrq.gov/issue/piece-my-mind-hard-times-and-hard-stops
Implementing new information systems can have unintended consequences on processes. This…
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psnet.ahrq.gov/node/60950/psn-pdf
September 23, 2020 - An effective intervention: limiting opioid prescribing as a
means of reducing opioid analgesic misuse, and
overdose deaths.
September 23, 2020
Fink BC, Uyttebrouck O, Larson RS. An effective intervention: limiting opioid prescribing as a means of
reducing opioid analgesic misuse, and overdose deaths. J Law Med Eth…
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psnet.ahrq.gov/node/47797/psn-pdf
June 14, 2019 - The impact of RVU-based compensation on patient safety
outcomes in outpatient otolaryngology procedures.
June 14, 2019
Stanisce L, Ahmad N, Deckard N, et al. The Impact of RVU-Based Compensation on Patient Safety
Outcomes in Outpatient Otolaryngology Procedures. Otolaryngol Head Neck Surg. 2019;160(6):1003-1008.
d…
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psnet.ahrq.gov/node/844783/psn-pdf
September 04, 2019 - A lethal hidden curriculum—death of a medical student
from opioid use disorder.
September 4, 2019
Lucey CR, Jones L, Eastburn A. A Lethal Hidden Curriculum - Death of a Medical Student from Opioid Use
Disorder. N Engl J Med. 2019;381(9):793-795. doi:10.1056/NEJMp1901537.
https://psnet.ahrq.gov/issue/lethal-hidden-…
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psnet.ahrq.gov/node/60845/psn-pdf
August 26, 2020 - Bridging the gap between culture and safety in a critical
care context: the role of work debate spaces.
August 26, 2020
Leuridan G. Bridging the gap between culture and safety in a critical care context: the role of work debate
spaces. Safety Sci. 2020;129:104839. doi:10.1016/j.ssci.2020.104839.
https://psnet.ahrq…
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psnet.ahrq.gov/node/866958/psn-pdf
October 16, 2024 - Beyond error: a qualitative study of human factors in
serious adverse events.
October 16, 2024
Mujuru C, Peisah C. Beyond error: a qualitative study of human factors in serious adverse events. J
Healthc Risk Manag. 2024;44(2):7-13. doi:10.1002/jhrm.21583.
https://psnet.ahrq.gov/issue/beyond-error-qualitative-study…
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psnet.ahrq.gov/node/46264/psn-pdf
August 09, 2017 - Intraoperative handoffs among anesthesia providers
increase the incidence of documentation errors for
controlled drugs.
August 9, 2017
Epstein RH, Dexter F, Gratch DM, et al. Intraoperative Handoffs Among Anesthesia Providers Increase the
Incidence of Documentation Errors for Controlled Drugs. Jt Comm J Qual Patie…
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psnet.ahrq.gov/node/47277/psn-pdf
August 08, 2018 - Students have a key role in a culture of safety: analysis of
student-associated medication incidents.
August 8, 2018
ISMP Medication Safety Alert! Acute care edition. July 26, 2018;23:1-4.
https://psnet.ahrq.gov/issue/students-have-key-role-culture-safety-analysis-student-associated-medication-
incidents
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