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psnet.ahrq.gov/node/848827/psn-pdf
May 10, 2023 - TQIP Mortality Reporting System Case Reports.
May 10, 2023
ACS TQIP Mortality Reporting System Writing Group. J Trauma Acute Care Surg. 2023.
https://psnet.ahrq.gov/issue/tqip-mortality-reporting-system-case-reports
Anonymous case reporting provides opportunities to examine unexpected patient harm instances to
pin…
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psnet.ahrq.gov/node/44848/psn-pdf
April 22, 2016 - Ambulatory medication reconciliation: using a
collaborative approach to process improvement at an
academic medical center.
April 22, 2016
Keogh C, Kachalia A, Fiumara K, et al. Ambulatory Medication Reconciliation: Using a Collaborative
Approach to Process Improvement at an Academic Medical Center. Jt Comm J Qual …
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psnet.ahrq.gov/node/45025/psn-pdf
May 04, 2016 - Reducing prognostic errors: a new imperative in quality
healthcare.
May 4, 2016
Khullar D, Jena AB. Reducing prognostic errors: a new imperative in quality healthcare. BMJ.
2016;352:i1417. doi:10.1136/bmj.i1417.
https://psnet.ahrq.gov/issue/reducing-prognostic-errors-new-imperative-quality-healthcare
This comment…
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psnet.ahrq.gov/node/44704/psn-pdf
February 09, 2016 - Sensemaking and the co-production of safety: a
qualitative study of primary medical care patients.
February 9, 2016
Rhodes P, McDonald R, Campbell S, et al. Sensemaking and the co-production of safety: a qualitative
study of primary medical care patients. Sociol Health Illn. 2016;38(2):270-285. doi:10.1111/1467-
9…
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psnet.ahrq.gov/node/35598/psn-pdf
July 10, 2008 - Residents report on adverse events and their causes.
July 10, 2008
Jagsi R, Kitch BT, Weinstein DF, et al. Residents report on adverse events and their causes. Arch Intern
Med. 2005;165(22):2607-13.
https://psnet.ahrq.gov/issue/residents-report-adverse-events-and-their-causes
This survey demonstrated that more tha…
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psnet.ahrq.gov/node/37275/psn-pdf
December 23, 2011 - Developing indicators of inpatient adverse drug events
through nonlinear analysis using administrative data.
December 23, 2011
Nebeker JR, Yarnold PR, Soltysik RC, et al. Developing indicators of inpatient adverse drug events through
nonlinear analysis using administrative data. Med Care. 2007;45(10 Supl 2):S81-8.
…
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psnet.ahrq.gov/node/38326/psn-pdf
January 14, 2009 - Results of a medication reconciliation survey from the
2006 Society of Hospital Medicine national meeting.
January 14, 2009
Clay BJ, Halasyamani L, Stucky ER, et al. Results of a medication reconciliation survey from the 2006
Society of Hospital Medicine national meeting. J Hosp Med. 2008;3(6). doi:10.1002/jhm.370.…
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psnet.ahrq.gov/node/846168/psn-pdf
March 15, 2023 - Now is the time to routinely ask patients about safety.
March 15, 2023
Gandhi TK. Now Is the Time to Routinely Ask Patients About Safety. Jt Comm J Qual Patient Saf.
2023;49(4):235-236. doi:10.1016/j.jcjq.2023.01.009.
https://psnet.ahrq.gov/issue/now-time-routinely-ask-patients-about-safety
Safety event reporting …
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psnet.ahrq.gov/node/47381/psn-pdf
April 03, 2019 - The role of the patient in patient safety: what can we learn
from healthcare's history?
April 3, 2019
Leistikow I, Huisman F. The role of the patient in patient safety: What can we learn from healthcare's
history? J Patient Saf Risk Manag. 2018;23(4):139-141. doi:10.1177/2516043518791051.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/866118/psn-pdf
June 12, 2024 - Factors Affecting the Delivery of Safe Care in Midwifery
Units.
June 12, 2024
Maternity and Newborn Safety Investigations Programme. Newcastle Upon Tyne, UK: Care Quality
Commission; May 2024.
https://psnet.ahrq.gov/issue/factors-affecting-delivery-safe-care-midwifery-units
Safe maternal care is a challenge world…
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psnet.ahrq.gov/node/41985/psn-pdf
October 26, 2016 - Legislative Report to the General Assembly: Adverse
Event Reporting.
October 26, 2016
Pino R, Furniss WH, Mueller L, Olson JC. Hartford, CT: Connecticut Department of Public Health; October
2016.
https://psnet.ahrq.gov/issue/legislative-report-general-assembly-adverse-event-reporting
This annual publication provi…
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psnet.ahrq.gov/node/50709/psn-pdf
December 04, 2019 - Cognitive engineering to improve patient safety and
outcomes in cardiothoracic surgery
December 4, 2019
Zenati MA, Kennedy-Metz L, Dias RD. Cognitive Engineering to Improve Patient Safety and Outcomes in
Cardiothoracic Surgery. Semin Thorac Cardiovasc Surg. 2019. doi:10.1053/j.semtcvs.2019.10.011.
https://psnet.ah…
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psnet.ahrq.gov/node/836835/psn-pdf
March 30, 2022 - Bias in mental health diagnosis gets in the way of
treatment.
March 30, 2022
Garb HN. Psyche. March 22, 2022.
https://psnet.ahrq.gov/issue/bias-mental-health-diagnosis-gets-way-treatment
A wide array of biases can affect clinical judgement and contribute to diagnostic error. This article
discusses the impact of i…
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psnet.ahrq.gov/node/43575/psn-pdf
April 22, 2015 - Patient safety challenges in low-income and middle-
income countries.
April 22, 2015
Steffner KR, McQueen KAK, Gelb AW. Patient safety challenges in low-income and middle-income
countries. Curr Opin Anaesthesiol. 2014;27(6):623-9. doi:10.1097/ACO.0000000000000121.
https://psnet.ahrq.gov/issue/patient-safety-challe…
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psnet.ahrq.gov/node/44900/psn-pdf
April 22, 2016 - When a surgical colleague makes an error.
April 22, 2016
Antiel RM, Blinman TA, Rentea RM, et al. When a Surgical Colleague Makes an Error. Pediatrics.
2016;137(3):e20153828. doi:10.1542/peds.2015-3828.
https://psnet.ahrq.gov/issue/when-surgical-colleague-makes-error
Physicians have become more comfortable with re…
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psnet.ahrq.gov/node/41648/psn-pdf
September 30, 2012 - Using an objective structured clinical examination to test
adherence to Joint Commission National Patient Safety
Goal–associated behaviors.
September 30, 2012
Pernar LIM, Shaw T, Pozner CN, et al. Using an Objective Structured Clinical Examination to test
adherence to Joint Commission National Patient Safety Goal-…
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psnet.ahrq.gov/node/42625/psn-pdf
November 08, 2013 - Miscount incidents: a novel approach to exploring risk
factors for unintentionally retained surgical items.
November 8, 2013
Judson TJ, Howell MD, Guglielmi C, et al. Miscount incidents: a novel approach to exploring risk factors for
unintentionally retained surgical items. Jt Comm J Qual Patient Saf. 2013;39(10):4…
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psnet.ahrq.gov/node/47067/psn-pdf
May 16, 2018 - Senior staff safety rounds: a commitment to ensure safety
is the top priority.
May 16, 2018
O'Connell RT, Ivy ME. NEJM Catalyst. May 1, 2018.
https://psnet.ahrq.gov/issue/senior-staff-safety-rounds-commitment-ensure-safety-top-priority
Leadership participation at the front lines can drive safety improvement work. …
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psnet.ahrq.gov/node/43768/psn-pdf
December 10, 2014 - Accountability in nursing practice: why it is important for
patient safety.
December 10, 2014
Battié R, Steelman VM. Accountability in nursing practice: why it is important for patient safety. AORN J.
2014;100(5):537-541. doi:10.1016/j.aorn.2014.08.008.
https://psnet.ahrq.gov/issue/accountability-nursing-practice-…
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psnet.ahrq.gov/node/43189/psn-pdf
December 15, 2014 - Twitter as a tool to enhance student engagement during
an interprofessional patient safety course.
December 15, 2014
Mckay M, Sanko JS, Shekhter I, et al. Twitter as a tool to enhance student engagement during an
interprofessional patient safety course. J Interprof Care. 2014;28(6):565-7.
doi:10.3109/13561820.2014…