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psnet.ahrq.gov/node/46920/psn-pdf
August 08, 2018 - Identification and characterization of failures in infectious
agent transmission precaution practices in hospitals: a
qualitative study.
August 8, 2018
Krein SL, Mayer J, Harrod M, et al. Identification and Characterization of Failures in Infectious Agent
Transmission Precaution Practices in Hospitals: A Qualitati…
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psnet.ahrq.gov/node/45815/psn-pdf
January 25, 2017 - Handoffs: transitions of care for children in the
emergency department.
January 25, 2017
American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of
Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association
Pediatric Committee. Pediatrics. 2016;138:…
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psnet.ahrq.gov/node/837671/psn-pdf
July 13, 2022 - Long-term care healthcare-associated infections in 2021:
an analysis of 17,971 reports.
July 13, 2022
Kepner S, Adkins JA, Jones RM. Long-term care healthcare-associated infections in 2021: an analysis of
17,971 reports. Patient Saf. 2022;4(2):6-17. doi:10.33940/data/2022.6.1.
https://psnet.ahrq.gov/issue/long-ter…
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psnet.ahrq.gov/node/849331/psn-pdf
May 24, 2023 - Long-term care healthcare-associated infections in 2022:
an analysis of 20,216 reports.
May 24, 2023
Kepner S, Bingman C, Jones RM. Long-term care healthcare-associated iInfections in 2022: an analysis of
20,216 reports. Patient Saf. 2023;5(2):20-31. doi:10.33940/001c.74494.
https://psnet.ahrq.gov/issue/long-term-…
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psnet.ahrq.gov/node/34784/psn-pdf
June 24, 2015 - The potential for improved teamwork to reduce medical
errors in the emergency department.
June 24, 2015
Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in
the emergency department. Ann Emerg Med. 2005;34(3):373-383. doi:10.1016/s0196-0644(99)70134-4.
https://ps…
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psnet.ahrq.gov/node/44898/psn-pdf
November 23, 2016 - Types and patterns of safety concerns in home care:
client and family caregiver perspectives.
November 23, 2016
Tong CE, Sims-Gould J, Martin-Matthews A. Types and patterns of safety concerns in home care: client
and family caregiver perspectives. Int J Qual Health Care. 2016;28(2):214-220.
doi:10.1093/intqhc/mzw0…
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psnet.ahrq.gov/node/74005/psn-pdf
October 27, 2021 - The postpartum hemorrhage patient safety bundle
implementation at a single institution: successes,
failures, and lessons learned,
October 27, 2021
Duzyj CM, Boyle C, Mahoney K, et al. The postpartum hemorrhage patient safety bundle implementation at
a single institution: successes, failures, and lessons learned. A…
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psnet.ahrq.gov/node/44344/psn-pdf
July 22, 2015 - Making healthcare safer by understanding, designing and
buying better IT.
July 22, 2015
Thimbleby H, Lewis A, Williams J. Making healthcare safer by understanding, designing and buying better
IT. Clin Med (Lond). 2015;15(3):258-62. doi:10.7861/clinmedicine.15-3-258.
https://psnet.ahrq.gov/issue/making-healthcare-s…
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psnet.ahrq.gov/node/47832/psn-pdf
February 27, 2019 - Another round of the blame game: a paralyzing criminal
indictment that recklessly "overrides" just culture.
February 27, 2019
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
https://psnet.ahrq.gov/issue/another-round-blame-game-paralyzing-criminal-indictment-recklessly-
overrides-just-cultu…
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psnet.ahrq.gov/node/851201/psn-pdf
July 05, 2023 - ‘I felt like I was dying’: how women with postpartum
depression fall through the cracks of U.S. health care.
July 5, 2023
Gammon K. STAT. June 26, 2023.
https://psnet.ahrq.gov/issue/i-felt-i-was-dying-how-women-postpartum-depression-fall-through-cracks-us-
health-care
The maternal mental health crisis results in …
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psnet.ahrq.gov/node/73474/psn-pdf
July 07, 2021 - Resident and family engagement in medication
management in aged care facilities: a systematic review.
July 7, 2021
Manias E, Bucknall T, Hutchinson AM, et al. Resident and family engagement in medication management
in aged care facilities: a systematic review. Expert Opin Drug Saf. 2021:1-19.
doi:10.1080/14740338.…
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psnet.ahrq.gov/node/47636/psn-pdf
December 12, 2018 - Learning from tragedy: the Julia Berg story.
December 12, 2018
Graber ML, Berg D, Jerde W, et al. Learning from tragedy: the Julia Berg story. Diagnosis (Berl).
2018;5(4):257-266. doi:10.1515/dx-2018-0067.
https://psnet.ahrq.gov/issue/learning-tragedy-julia-berg-story
This commentary provides a clinical review of …
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psnet.ahrq.gov/node/34677/psn-pdf
February 09, 2011 - Patients' and physicians' attitudes regarding the
disclosure of medical errors.
February 9, 2011
Gallagher TH, Waterman AD, Ebers AG, et al. Patients' and physicians' attitudes regarding the disclosure
of medical errors. JAMA. 2003;289(8):1001-7.
https://psnet.ahrq.gov/issue/patients-and-physicians-attitudes-regar…
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psnet.ahrq.gov/node/44877/psn-pdf
April 27, 2016 - Actions Needed to Help Ensure Appropriate Medication
Continuation and Prescribing Practices.
April 27, 2016
Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16-
158.
https://psnet.ahrq.gov/issue/actions-needed-help-ensure-appropriate-medication-continuation-and-
pre…
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psnet.ahrq.gov/node/47595/psn-pdf
March 06, 2019 - Approaches and Challenges to Electronically Matching
Patients' Records Across Providers.
March 6, 2019
Washington, DC: United States Government Accountability Office; January 2019. Publication GAO-19-197.
https://psnet.ahrq.gov/issue/approaches-and-challenges-electronically-matching-patients-records-across-
provid…
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psnet.ahrq.gov/node/35365/psn-pdf
February 17, 2011 - Accidental deaths, saved lives, and improved quality.
February 17, 2011
Brennan TA, Gawande AA, Thomas EJ, et al. Accidental Deaths, Saved Lives, and Improved Quality. New
England Journal of Medicine. 2005;353(13). doi:10.1056/nejmsb051157.
https://psnet.ahrq.gov/issue/accidental-deaths-saved-lives-and-improved-qua…
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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/45457/psn-pdf
September 01, 2016 - Patient safety implications of electronic alerts and alarms
of maternal–fetal status during labor.
September 1, 2016
Simpson KR, Lyndon A, Davidson LA. Patient Safety Implications of Electronic Alerts and Alarms of
Maternal - Fetal Status During Labor. Nurs Womens Health. 2016;20(4):358-66.
doi:10.1016/j.nwh.2016.…
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psnet.ahrq.gov/node/34777/psn-pdf
February 16, 2011 - Systems errors versus physicians' errors: finding the
balance in medical education.
February 16, 2011
Casarett D, Helms C. Systems errors versus physicians' errors: finding the balance in medical education.
Acad Med. 1999;74(1):19-22.
https://psnet.ahrq.gov/issue/systems-errors-versus-physicians-errors-finding-bal…
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psnet.ahrq.gov/node/43108/psn-pdf
September 28, 2023 - Maryland Hospital Patient Safety Program Annual Report.
September 28, 2023
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.
https://psnet.ahrq.gov/issue/maryland-hospital-patient-safety-program-annual-report
This annual report summarizes never events in Maryland hospit…