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psnet.ahrq.gov/node/37368/psn-pdf
January 10, 2017 - Effective implementation of work-hour limits and
systemic improvements.
January 10, 2017
Landrigan CP, Czeisler CA, Barger LK, et al. Effective implementation of work-hour limits and systemic
improvements. Jt Comm J Qual Patient Saf. 2007;33(11 Suppl):19-29.
https://psnet.ahrq.gov/issue/effective-implementation-wo…
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psnet.ahrq.gov/node/838251/psn-pdf
October 05, 2022 - Serious hazards of transfusion: evaluating the dangers of
a wrong patient autologous salvaged blood in cardiac
surgery.
October 5, 2022
Uramatsu M, Maeda H, Mishima S, et al. Serious hazards of transfusion: evaluating the dangers of a wrong
patient autologous salvaged blood in cardiac surgery. J Cardiothorac Surg.…
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psnet.ahrq.gov/node/840170/psn-pdf
November 16, 2022 - Predicting dispensing errors in community pharmacies:
an application of the Systematic Human Error Reduction
and Prediction Approach (SHERPA).
November 16, 2022
Ashour A, Phipps DL, Ashcroft DM. PLoS ONE. 2022;17(1):e0261672.
https://psnet.ahrq.gov/innovation/predicting-dispensing-errors-community-pharmacies-…
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psnet.ahrq.gov/node/38142/psn-pdf
April 30, 2014 - Medical error disclosure among pediatricians: choosing
carefully what we might say to parents.
April 30, 2014
Loren DJ, Klein EJ, Garbutt J, et al. Medical Error Disclosure Among Pediatricians. Arch Pediatr Adolesc
Med. 2008;162(10):922-927. doi:10.1001/archpedi.162.10.922.
https://psnet.ahrq.gov/issue/medical-err…
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psnet.ahrq.gov/node/42835/psn-pdf
April 21, 2015 - Hospital board oversight of quality and patient safety: a
narrative review and synthesis of recent empirical
research.
April 21, 2015
Millar R, Mannion R, Freeman T, et al. Hospital board oversight of quality and patient safety: a narrative
review and synthesis of recent empirical research. Milbank Q. 2013;91(4):7…
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psnet.ahrq.gov/node/47282/psn-pdf
August 08, 2018 - Making surgical wards safer for patients with diabetes:
reducing hypoglycaemia and insulin errors.
August 8, 2018
Singh A, Adams A, Dudley B, et al. Making surgical wards safer for patients with diabetes: reducing
hypoglycaemia and insulin errors. BMJ Open Qual. 2018;7(3):e000312. doi:10.1136/bmjoq-2017-000312.
ht…
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psnet.ahrq.gov/node/42113/psn-pdf
March 20, 2013 - Preventing in-facility pressure ulcers as a patient safety
strategy: a systematic review.
March 20, 2013
Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic
review. Ann Intern Med. 2013;158(5 Pt 2):410-416. doi:10.7326/0003-4819-158-5-201303051-00008.
https:/…
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psnet.ahrq.gov/node/40448/psn-pdf
September 19, 2016 - Health care workers as second victims of medical errors.
September 19, 2016
Edrees HH, Paine LA, Feroli R, et al. Health care workers as second victims of medical errors. Pol Arch
Med Wewn. 2011;121(4):101-108.
https://psnet.ahrq.gov/issue/health-care-workers-second-victims-medical-errors
Medical errors can have a…
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psnet.ahrq.gov/node/45216/psn-pdf
June 08, 2016 - Ambulatory computerized prescribing and preventable
adverse drug events.
June 8, 2016
Overhage JM, Gandhi TK, Hope C, et al. Ambulatory Computerized Prescribing and Preventable Adverse
Drug Events. J Patient Saf. 2016;12(2):69-74. doi:10.1097/PTS.0000000000000194.
https://psnet.ahrq.gov/issue/ambulatory-computeriz…
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psnet.ahrq.gov/node/865973/psn-pdf
May 29, 2024 - Physician antipsychotic overprescribing letters and
cognitive, behavioral, and physical health outcomes
among people with dementia: a secondary analysis of a
randomized clinical trial.
May 29, 2024
Harnisch M, Barnett ML, Coussens S, et al. Physician antipsychotic overprescribing letters and cognitive,
behavioral…
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psnet.ahrq.gov/node/35611/psn-pdf
June 23, 2010 - Error or "act of God"? A study of patients' and operating
room team members' perceptions of error definition,
reporting, and disclosure.
June 23, 2010
Espin S, Levinson W, Regehr G, et al. Error or "act of God"? A study of patients' and operating room team
members' perceptions of error definition, reporting, and d…
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psnet.ahrq.gov/node/39800/psn-pdf
January 19, 2011 - Medication errors in paediatric outpatients.
January 19, 2011
Kaushal R, Goldmann DA, Keohane CA, et al. Medication errors in paediatric outpatients. BMJ Qual Saf.
2010;19(6). doi:10.1136/qshc.2008.031179.
https://psnet.ahrq.gov/issue/medication-errors-paediatric-outpatients
Pediatric medication errors are common …
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psnet.ahrq.gov/node/44042/psn-pdf
November 03, 2015 - Deployment of rapid response teams by 31 hospitals in a
statewide collaborative.
November 3, 2015
Stolldorf DP, Jones CB. Deployment of rapid response teams by 31 hospitals in a statewide collaborative.
Jt Comm J Qual Patient Saf. 2015;41(4):186-191.
https://psnet.ahrq.gov/issue/deployment-rapid-response-teams-31-…
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psnet.ahrq.gov/node/45037/psn-pdf
February 15, 2017 - Disclosing large scale adverse events in the US Veterans
Health Administration: lessons from media responses.
February 15, 2017
Maguire EM, Bokhour BG, Asch SM, et al. Disclosing large scale adverse events in the US Veterans
Health Administration: lessons from media responses. Public Health. 2016;135:75-82.
doi:10…
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psnet.ahrq.gov/node/47313/psn-pdf
September 12, 2018 - The Lawrence D. Dorr Surgical Techniques &
Technologies Award: "Running two rooms" does not
compromise outcomes or patient safety in joint
arthroplasty.
September 12, 2018
Hamilton WG, Ho H, Parks NL, et al. The Lawrence D. Dorr Surgical Techniques & Technologies Award:
"Running Two Rooms" Does Not Compromise Out…
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psnet.ahrq.gov/node/36279/psn-pdf
May 27, 2011 - Evaluation of laboratory monitoring alerts within a
computerized physician order entry system for
medication orders.
May 27, 2011
Palen TE, Raebel MA, Lyons E, et al. Evaluation of laboratory monitoring alerts within a computerized
physician order entry system for medication orders. Am J Manag Care. 2006;12(7):389…
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psnet.ahrq.gov/node/38047/psn-pdf
January 31, 2011 - Single-patient rooms for safe patient-centered hospitals.
January 31, 2011
Detsky ME. Single-Patient Rooms for Safe Patient-Centered Hospitals. JAMA. 2008;300(8).
doi:10.1001/jama.300.8.954.
https://psnet.ahrq.gov/issue/single-patient-rooms-safe-patient-centered-hospitals
Providing patient-centered care continues …
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psnet.ahrq.gov/node/37690/psn-pdf
April 16, 2008 - How willing are patients to question healthcare staff on
issues related to the quality and safety of their
healthcare? An exploratory study.
April 16, 2008
Davis R, Koutantji M, Vincent C. How willing are patients to question healthcare staff on issues related to
the quality and safety of their healthcare? An expl…
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psnet.ahrq.gov/node/41925/psn-pdf
November 26, 2014 - Medication reconciliation accuracy and patient
understanding of intended medication changes on
hospital discharge.
November 26, 2014
Ziaeian B, Araujo KLB, Van Ness PH, et al. Medication reconciliation accuracy and patient understanding
of intended medication changes on hospital discharge. J Gen Intern Med. 2012;2…
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psnet.ahrq.gov/node/36308/psn-pdf
January 05, 2017 - A trigger tool to identify adverse events in the intensive
care unit.
January 5, 2017
Resar RK, Rozich JD, Simmonds T, et al. A Trigger Tool to Identify Adverse Events in the Intensive Care
Unit. The Joint Commission Journal on Quality and Patient Safety. 2016;32(10). doi:10.1016/s1553-
7250(06)32076-4.
https://…