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psnet.ahrq.gov/node/852450/psn-pdf
August 16, 2023 - Incidence and severity of medication reconciliation
discrepancies in trauma patients.
August 16, 2023
Dunbar EG, Massey AC, Lee YL, et al. Incidence and severity of medication reconciliation discrepancies in
trauma patients. Am Surg. 2023;89(7):3272-3274. doi:10.1177/00031348231161686.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/74073/psn-pdf
November 17, 2021 - Use of artificial intelligence for image analysis in breast
cancer screening programmes: systematic review of test
accuracy.
November 17, 2021
Freeman K, Geppert J, Stinton C, et al. Use of artificial intelligence for image analysis in breast cancer
screening programmes: systematic review of test accuracy. BMJ. 20…
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psnet.ahrq.gov/node/46237/psn-pdf
June 21, 2017 - Identifying and analyzing diagnostic paths: a new
approach for studying diagnostic practices.
June 21, 2017
Rao G, Epner P, Bauer V, et al. Identifying and analyzing diagnostic paths: a new approach for studying
diagnostic practices. Diagnosis (Berl). 2017;4(2):67-72. doi:10.1515/dx-2016-0049.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/74088/psn-pdf
November 17, 2021 - Surgical teams' attitudes about surgical safety and the
surgical safety checklist at 10 years: a multinational
survey.
November 17, 2021
Urban D, Burian BK, Patel K, et al. Surgical teams' attitudes about surgical safety and the surgical safety
checklist at 10 years: a multinational survey. Ann Surg. 2021;2(3):e07…
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psnet.ahrq.gov/node/44741/psn-pdf
January 20, 2016 - System hazards in managing laboratory test requests and
results in primary care: medical protection database
analysis and conceptual model.
January 20, 2016
Bowie P, Price J, Hepworth N, et al. System hazards in managing laboratory test requests and results in
primary care: medical protection database analysis and…
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psnet.ahrq.gov/node/44669/psn-pdf
January 22, 2016 - Safety standards: implementing fall prevention
interventions and sustaining lower fall rates by promoting
the culture of safety on an inpatient rehabilitation unit.
January 22, 2016
Leone RM, Adams RJ. Safety Standards: Implementing Fall Prevention Interventions and Sustaining Lower
Fall Rates by Promoting the Cul…
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psnet.ahrq.gov/node/837762/psn-pdf
August 03, 2022 - A scoping review of real-time automated clinical
deterioration alerts and evidence of impacts on
hospitalised patient outcomes.
August 3, 2022
Blythe R, Parsons R, White NM, et al. A scoping review of real-time automated clinical deterioration alerts
and evidence of impacts on hospitalised patient outcomes. BMJ Qu…
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psnet.ahrq.gov/node/73081/psn-pdf
March 31, 2021 - Health professionals' perspectives of safety issues in
mental health services: a qualitative study.
March 31, 2021
Albutt AK, Berzins K, Louch G, et al. Health professionals’ perspectives of safety issues in mental health
services: A qualitative study. nt J Ment Health Nurs. 2021;30(3):798-810. doi:10.1111/inm.1283…
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psnet.ahrq.gov/node/47980/psn-pdf
May 01, 2019 - Intensive care medicine in 2050: preventing harm.
May 1, 2019
Beet C, Benoit D, Bion J. Intensive care medicine in 2050: preventing harm. Intensive Care Med.
2019;45(4):505-507. doi:10.1007/s00134-018-5353-z.
https://psnet.ahrq.gov/issue/intensive-care-medicine-2050-preventing-harm
This commentary discusses curren…
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psnet.ahrq.gov/node/47996/psn-pdf
January 01, 2021 - Building an ambulatory safety program at an academic
health system.
May 15, 2019
Desai S, Fiumara K, Kachalia A. Building an Ambulatory Safety Program at an Academic Health System. J
Patient Saf. 2021;17(2):e84-e90. doi:10.1097/PTS.0000000000000594.
https://psnet.ahrq.gov/issue/building-ambulatory-safety-program-a…
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psnet.ahrq.gov/node/47554/psn-pdf
November 07, 2018 - Diagnostic Excellence Initiative.
November 7, 2018
Gordon and Betty Moore Foundation.
https://psnet.ahrq.gov/issue/diagnostic-excellence-improving-experience-and-outcomes-patient-care
Missed or delayed diagnoses lead to delays in care and significant preventable harm for patients. Despite
an increasing focus on di…
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psnet.ahrq.gov/node/45256/psn-pdf
July 01, 2017 - Applied use of safety event occurrence control charts of
harm and non-harm events: a case study.
July 1, 2017
Robinson SN, Neyens DM, Diller T. Applied Use of Safety Event Occurrence Control Charts of Harm and
Non-Harm Events: A Case Study. Am J Med Qual. 2017;32(3):285-291. doi:10.1177/1062860616646197.
https://p…
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psnet.ahrq.gov/node/837345/psn-pdf
June 08, 2022 - A checklist to address implicit bias in healthcare settings
during the COVID-19 pandemic: The PLACE Strategy.
June 8, 2022
Galiatsatos P, O'Conor KJ, Wilson C, et al. A checklist to address implicit bias in healthcare settings during
the COVID-19 pandemic: The PLACE Strategy. Health Secur. 2022;20(3):261-263.
doi:…
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psnet.ahrq.gov/node/39030/psn-pdf
October 21, 2009 - Misleading one detail: a preventable mode of diagnostic
error?
October 21, 2009
Arzy S, Brezis M, Khoury S, et al. Misleading one detail: a preventable mode of diagnostic error? J Eval
Clin Pract. 2009;15(5):804-6. doi:10.1111/j.1365-2753.2008.01098.x.
https://psnet.ahrq.gov/issue/misleading-one-detail-preventable…
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psnet.ahrq.gov/node/47745/psn-pdf
March 06, 2019 - "I am administering medication—please do not interrupt
me": red tabards preventing interruptions as perceived by
surgical patients.
March 6, 2019
Palese A, Ferro M, Pascolo M, et al. "I Am Administering Medication-Please Do Not Interrupt Me": Red
Tabards Preventing Interruptions as Perceived by Surgical Patients. …
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psnet.ahrq.gov/node/47618/psn-pdf
January 30, 2019 - Making care better in the pediatric intensive care unit.
January 30, 2019
Wolfe HA, Mack EH. Making care better in the pediatric intensive care unit. Transl Pediatr. 2018;7(4):267-
274. doi:10.21037/tp.2018.09.10.
https://psnet.ahrq.gov/issue/making-care-better-pediatric-intensive-care-unit
Pediatric critical care…
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psnet.ahrq.gov/node/866858/psn-pdf
October 02, 2024 - Electronic health record nudges and health care quality
and outcomes in primary care: a systematic review.
October 2, 2024
Nguyen OT, Kunta AR, Katoju SV, et al. Electronic health record nudges and health care quality and
outcomes in primary care: a systematic review. JAMA Netw Open. 2024;7(9):e2432760.
doi:10.100…
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psnet.ahrq.gov/node/42897/psn-pdf
March 12, 2017 - Teams, tribes and patient safety: overcoming barriers to
effective teamwork in healthcare.
March 12, 2017
Weller J, Boyd M, Cumin D. Teams, tribes and patient safety: overcoming barriers to effective teamwork in
healthcare. Postgrad Med J. 2014;90(1061):149-54. doi:10.1136/postgradmedj-2012-131168.
https://psnet.a…
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psnet.ahrq.gov/node/46984/psn-pdf
April 04, 2018 - Educator toolkits on second victim syndrome,
mindfulness and meditation, and positive psychology: the
2017 Resident Wellness Consensus Summit.
April 4, 2018
Chung AS, Smart J, Zdradzinski M, et al. Educator Toolkits on Second Victim Syndrome, Mindfulness and
Meditation, and Positive Psychology: The 2017 Resident W…
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psnet.ahrq.gov/node/60598/psn-pdf
June 17, 2020 - Associations of workflow disruptions in the operating
room with surgical outcomes: a systematic review and
narrative synthesis.
June 17, 2020
Koch A, Burns J, Catchpole K, et al. Associations of workflow disruptions in the operating room with
surgical outcomes: a systematic review and narrative synthesis. BMJ Qual…