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psnet.ahrq.gov/node/47486/psn-pdf
January 27, 2019 - Direct oral anticoagulants: a review of common
medication errors.
January 27, 2019
Barr D, Epps QJ. Direct oral anticoagulants: a review of common medication errors. J Thromb
Thrombolysis. 2019;47(1):146-154. doi:10.1007/s11239-018-1752-9.
https://psnet.ahrq.gov/issue/direct-oral-anticoagulants-review-common-medic…
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psnet.ahrq.gov/node/861763/psn-pdf
January 31, 2024 - The process and perspective of serious incident
investigations in adult community mental health services:
integrative review and synthesis.
January 31, 2024
Haylor H, Sparkes T, Armitage G, et al. The process and perspective of serious incident investigations in
adult community mental health services: integrative …
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psnet.ahrq.gov/node/855422/psn-pdf
November 15, 2023 - An exploratory analysis of the association between
hospital quality measures and financial performance.
November 15, 2023
Beauvais B, Dolezel D, Ramamonjiarivelo Z. An exploratory analysis of the association between hospital
quality measures and financial performance. Healthcare (Basel). 2023;11(20):2758.
doi:10.3…
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psnet.ahrq.gov/node/73865/psn-pdf
September 22, 2021 - Second victims among baccalaureate nursing students in
the aftermath of a patient safety incident: an exploratory
cross-sectional study.
September 22, 2021
Van Slambrouck L, Verschueren R, Seys D, et al. Second victims among baccalaureate nursing students in
the aftermath of a patient safety incident: an explorato…
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psnet.ahrq.gov/node/836829/psn-pdf
March 30, 2022 - Safety in fragile, conflict-affected, and vulnerable
settings: An evidence scanning approach for identifying
patient safety interventions.
March 30, 2022
O’Brien N, Shaw A, Flott K, et al. Safety in fragile, conflict-affected, and vulnerable settings: an evidence
scanning approach for identifying patient safety in…
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psnet.ahrq.gov/node/837144/psn-pdf
May 18, 2022 - Differences in hospitals' workplace violence incident
reporting practices: a mixed methods study.
May 18, 2022
Odes R, Chapman SM, Ackerman SL, et al. Differences in hospitals' workplace violence incident reporting
practices: a mixed methods study. Policy Polit Nurs Pract. 2022;23(2):98-108.
doi:10.1177/1527154422…
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psnet.ahrq.gov/node/46665/psn-pdf
June 19, 2018 - A qualitative study of patient involvement in medicines
management after hospital discharge: an under-
recognised source of systems resilience.
June 19, 2018
Fylan B, Armitage G, Naylor D, et al. A qualitative study of patient involvement in medicines management
after hospital discharge: an under-recognised source…
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psnet.ahrq.gov/node/44165/psn-pdf
May 27, 2015 - Unplanned return to theater: a quality of care and risk
management index?
May 27, 2015
Pujol N, Merrer J, Lemaire B, et al. Unplanned return to theater: A quality of care and risk management
index? Orthop Traumatol Surg Res. 2015;101(4):399-403. doi:10.1016/j.otsr.2015.03.013.
https://psnet.ahrq.gov/issue/unplanne…
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psnet.ahrq.gov/node/47608/psn-pdf
March 20, 2019 - Use of a public health law framework to improve
medication safety by anesthesia providers.
March 20, 2019
Litman RS. Use of a public health law framework to improve medication safety by anesthesia providers. J
Patient Saf Risk Manag. 2019;24(4):158-165. doi:10.1177/2516043518825383.
https://psnet.ahrq.gov/issue/us…
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psnet.ahrq.gov/node/859343/psn-pdf
December 20, 2023 - Reducing retained foreign objects in the operating room:
a quality improvement initiative.
December 20, 2023
Keane OA, Chambers C, Brady CM, et al. Reducing retained foreign objects in the operating room: a
quality improvement initiative. J Am Coll Surg. 2023;237(6):864-872. doi:10.1097/xcs.0000000000000847.
https…
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psnet.ahrq.gov/node/44914/psn-pdf
February 15, 2017 - Safer prescribing—a trial of education, informatics, and
financial incentives.
February 15, 2017
Dreischulte T, Donnan P, Grant A, et al. Safer Prescribing--A Trial of Education, Informatics, and Financial
Incentives. N Engl J Med. 2016;374(11):1053-64. doi:10.1056/NEJMsa1508955.
https://psnet.ahrq.gov/issue/safer…
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psnet.ahrq.gov/node/839820/psn-pdf
November 09, 2022 - Patients who die by suicide: a study of treatment patterns
and patient safety incidents in Norway.
November 9, 2022
Krvavac S, Jansson B, Bukholm IRK, et al. Patients who die by suicide: a study of treatment patterns and
patient safety incidents in Norway. Int J Environ Res Public Health. 2022;19(17):10686.
doi:10…
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psnet.ahrq.gov/node/34690/psn-pdf
February 10, 2011 - Systems analysis of adverse drug events.
February 10, 2011
Leape L, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. ADE Prevention Study
Group. JAMA. 1995;274(1):35-43.
https://psnet.ahrq.gov/issue/systems-analysis-adverse-drug-events
The authors report a "systems analysis" of the adverse drug…
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psnet.ahrq.gov/node/38121/psn-pdf
October 08, 2008 - Impact of date stamping on patient safety measurement in
patients undergoing CABG: experience with the AHRQ
Patient Safety Indicators.
October 8, 2008
Glance LG, Li Y, Osler T, et al. Impact of date stamping on patient safety measurement in patients
undergoing CABG: experience with the AHRQ Patient Safety Indicato…
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psnet.ahrq.gov/node/864848/psn-pdf
March 20, 2024 - An mHealth design to promote medication safety in
children with medical complexity.
March 20, 2024
Jolliff A, Coller RJ, Kearney H, et al. An mHealth design to promote medication safety in children with
medical complexity. Appl Clin Inform. 2024;15(1):45-54. doi:10.1055/a-2214-8000.
https://psnet.ahrq.gov/issue/mh…
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psnet.ahrq.gov/node/34952/psn-pdf
November 17, 2011 - Assessing the National Electronic Injury Surveillance
System—Cooperative Adverse Drug Event Surveillance
Project—six sites, United States, January 1–June 15,
2004.
November 17, 2011
Prevention C for DC and. Assessing the National Electronic Injury Surveillance System-Cooperative
Adverse Drug Event Surveillance pr…
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psnet.ahrq.gov/node/60050/psn-pdf
March 18, 2020 - Zero harm in health care.
March 18, 2020
Gandhi TK, Feeley D, Schummers D. Zero Harm in Health Care. NEJM Catal Innov Care Deliv. 2020;1(2).
doi:10.1056/cat.19.1137.
https://psnet.ahrq.gov/issue/zero-harm-health-care
Health systems are encouraged to strive for zero preventable harm, but achieving this goal require…
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psnet.ahrq.gov/node/44405/psn-pdf
September 02, 2015 - Ranking hospitals on avoidable death rates derived from
retrospective case record review: methodological
observations and limitations.
September 2, 2015
Abel G, Lyratzopoulos G. Ranking hospitals on avoidable death rates derived from retrospective case
record review: methodological observations and limitations. BM…
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psnet.ahrq.gov/node/73879/psn-pdf
September 29, 2021 - Evolving factors in hospital safety: a systematic review
and meta-analysis of hospital adverse events.
September 29, 2021
Sauro KM, Machan M, Whalen-Browne L, et al. Evolving factors in hospital safety: a systematic review and
meta-analysis of hospital adverse events. J Patient Saf. 2021;17(8):e1285-e1295.
doi:10.…
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psnet.ahrq.gov/node/74838/psn-pdf
February 16, 2022 - Overstating inpatient deaths due to medical error erodes
trust in healthcare and the patient safety movement.
February 16, 2022
Gunderson CG, Rodwin BA. Overstating inpatient deaths due to medical error erodes trust in healthcare
and the patient safety movement. J Hosp Med. 2022;17(5):399-402. doi:10.1002/jhm.2768.…