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psnet.ahrq.gov/node/44285/psn-pdf
November 06, 2015 - Hospital board oversight of quality and safety: a
stakeholder analysis exploring the role of trust and
intelligence.
November 6, 2015
Millar R, Freeman T, Mannion R. Hospital board oversight of quality and safety: a stakeholder analysis
exploring the role of trust and intelligence. BMC Health Serv Res. 2015;15:196…
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psnet.ahrq.gov/node/46242/psn-pdf
June 21, 2017 - Day passes for vulnerable patients of psychiatric
hospitals can have dangerous, even fatal consequences.
June 21, 2017
Woodruff E. Baltimore Sun. June 9, 2017.
https://psnet.ahrq.gov/issue/day-passes-vulnerable-patients-psychiatric-hospitals-can-have-dangerous-
even-fatal
Psychiatric patients are vulnerable to pa…
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psnet.ahrq.gov/node/43459/psn-pdf
August 27, 2014 - Serious Reportable Events.
August 27, 2014
Nova Scotia Department of Health and Wellness.
https://psnet.ahrq.gov/issue/serious-reportable-events
Incident reporting systems are an important method for capturing, analyzing, and learning about a broad
range of potential safety issues. This Web site provides access to…
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psnet.ahrq.gov/node/44895/psn-pdf
March 09, 2016 - On patient safety: when are we too old to operate?
March 9, 2016
Lee MJ. On Patient Safety: When Are We Too Old to Operate? Clin Orthop Relat Res. 2016;474(4):895-8.
doi:10.1007/s11999-016-4722-6.
https://psnet.ahrq.gov/issue/patient-safety-when-are-we-too-old-operate
High-risk industries often have mandatory requ…
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psnet.ahrq.gov/node/41624/psn-pdf
November 06, 2012 - How nurses and physicians judge their own quality of
care for deteriorating patients on medical wards: self-
assessment of quality of care is suboptimal.
November 6, 2012
Ludikhuize J, Dongelmans DA, Smorenburg SM, et al. How nurses and physicians judge their own quality
of care for deteriorating patients on medic…
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psnet.ahrq.gov/node/45264/psn-pdf
September 01, 2016 - Perceived factors associated with sustained improvement
following participation in a multicenter quality
improvement collaborative.
September 1, 2016
Stone S, Lee HC, Sharek PJ. Perceived Factors Associated with Sustained Improvement Following
Participation in a Multicenter Quality Improvement Collaborative. Jt Co…
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psnet.ahrq.gov/node/34978/psn-pdf
June 30, 2011 - Personal digital assistant-based drug information
sources: potential to improve medication safety.
June 30, 2011
Galt K, Rule AM, Houghton B, et al. Personal digital assistant-based drug information sources: potential to
improve medication safety. J Med Libr Assoc. 2005;93(2):229-36.
https://psnet.ahrq.gov/issue/p…
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psnet.ahrq.gov/node/46248/psn-pdf
October 23, 2018 - Medical errors, malpractice, and defensive medicine: an
ill-fated triad.
October 23, 2018
Berlin L. Medical errors, malpractice, and defensive medicine: an ill-fated triad. Diagnosis (Berl).
2017;4(3):133-139. doi:10.1515/dx-2017-0007.
https://psnet.ahrq.gov/issue/medical-errors-malpractice-and-defensive-medicine-…
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psnet.ahrq.gov/node/43034/psn-pdf
March 12, 2014 - Implementation of a pediatric rapid response team:
experience of the Hospital for Sick Children in Toronto.
March 12, 2014
Kukreti V, Gaiteiro R, Mohseni-Bod H. Implementation of a pediatric rapid response team: experience of
the Hospital for Sick Children in Toronto. Indian Pediatr. 2014;51(1):11-5.
https://psnet…
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psnet.ahrq.gov/node/35127/psn-pdf
February 24, 2011 - Beyond the medical record: other modes of error
acknowledgment.
February 24, 2011
Rosenthal M, Cornett PL, Sutcliffe K, et al. Beyond the medical record: other modes of error
acknowledgment. J Gen Intern Med. 2005;20(5):404-9.
https://psnet.ahrq.gov/issue/beyond-medical-record-other-modes-error-acknowledgment
Thi…
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psnet.ahrq.gov/node/38747/psn-pdf
September 16, 2009 - Examination of how a survey can spur culture changes
using a quality improvement approach: a region-wide
approach to determining a patient safety culture.
September 16, 2009
Pringle J, Weber RJ, Rice K, et al. Examination of how a survey can spur culture changes using a quality
improvement approach: a region-wide …
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psnet.ahrq.gov/node/46711/psn-pdf
July 01, 2019 - The STOP Measure. Safe and Transparent Opioid
Prescribing to Promote Patient Safety and Reduced Risk
of Opioid Misuse.
July 1, 2019
Washington, DC: America's Health Insurance Plans; 2019.
https://psnet.ahrq.gov/issue/stop-measure-safe-and-transparent-opioid-prescribing-promote-patient-safety-
and-reduced-risk
Gu…
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psnet.ahrq.gov/node/45234/psn-pdf
November 18, 2016 - Recommended responsibilities for management of MR
safety.
November 18, 2016
Calamante F, Ittermann B, Kanal E, et al. Recommended responsibilities for management of MR safety. J
Magn Reson Imaging. 2016;44(5):1067-1069. doi:10.1002/jmri.25282.
https://psnet.ahrq.gov/issue/recommended-responsibilities-management-mr…
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psnet.ahrq.gov/node/73075/psn-pdf
March 24, 2021 - Analysis of transdermal medication patch errors
uncovers a “patchwork” of safety challenges.
March 24, 2021
ISMP Medication Safety Alert! Acute Care. March 11, 2021;26(5):1-6.
https://psnet.ahrq.gov/issue/analysis-transdermal-medication-patch-errors-uncovers-patchwork-safety-
challenges
Skin patches are a conveni…
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psnet.ahrq.gov/node/34800/psn-pdf
December 23, 2008 - A classification system for incidents and accidents in the
health-care system.
December 23, 2008
Runciman WB, Helps SC, Sexton EJ, et al. A classification for incidents and accidents in the health-care
system. J Qual Clin Pract. 1998;18(3):199-211.
https://psnet.ahrq.gov/issue/classification-system-incidents-and-a…
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psnet.ahrq.gov/node/44140/psn-pdf
July 15, 2015 - Openness and Honesty When Things Go Wrong: the
Professional Duty of Candour.
July 15, 2015
London, UK: General Medical Council and the Nursing and Midwifery Council; June 29, 2015.
https://psnet.ahrq.gov/issue/openness-and-honesty-when-things-go-wrong-professional-duty-candour
Open and honest discussion with patie…
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psnet.ahrq.gov/node/44638/psn-pdf
May 18, 2016 - Developing an appreciation of patient safety: analysis of
interprofessional student experiences with health
mentors.
May 18, 2016
Langlois S. Developing an appreciation of patient safety: analysis of interprofessional student experiences
with health mentors. Perspect Med Educ. 2016;5(2):88-94. doi:10.1007/s40037-0…
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psnet.ahrq.gov/node/854993/psn-pdf
November 01, 2023 - Building cultures of high reliability: lessons from the high
reliability organization paradigm.
November 1, 2023
Sutcliffe KM. Building cultures of high reliability: lessons from the high reliability organization paradigm.
Anesthesiol Clin. 2023;41(4):707-717. doi:10.1016/j.anclin.2023.03.012.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/44417/psn-pdf
January 25, 2016 - Health information exchange in emergency medicine.
January 25, 2016
Shapiro JS, Crowley D, Hoxhaj S, et al. Health Information Exchange in Emergency Medicine. Ann Emerg
Med. 2016;67(2):216-26. doi:10.1016/j.annemergmed.2015.06.018.
https://psnet.ahrq.gov/issue/health-information-exchange-emergency-medicine
Insuffi…
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psnet.ahrq.gov/node/839312/psn-pdf
November 02, 2022 - Documenting the indication for antimicrobial prescribing:
a scoping review.
November 2, 2022
Saini S, Leung V, Si E, et al. Documenting the indication for antimicrobial prescribing: a scoping review.
BMJ Qual Saf. 2022;31(11):787-799. doi:10.1136/bmjqs-2021-014582.
https://psnet.ahrq.gov/issue/documenting-indicati…