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psnet.ahrq.gov/node/43681/psn-pdf
June 03, 2016 - Learning from failure: the need for independent safety
investigation in healthcare.
June 3, 2016
Macrae C, Vincent CA. Learning from failure: the need for independent safety investigation in healthcare. J
R Soc Med. 2014;107(11):439-443. doi:10.1177/0141076814555939.
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psnet.ahrq.gov/node/37912/psn-pdf
September 25, 2008 - Association of a clinical knowledge support system with
improved patient safety, reduced complications and
shorter length of stay among Medicare beneficiaries in
acute care hospitals in the United States.
September 25, 2008
Bonis PA, Pickens GT, Rind DM, et al. Association of a clinical knowledge support system wi…
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psnet.ahrq.gov/node/47109/psn-pdf
June 06, 2018 - Principles of automation for patient safety in intensive
care: learning from aviation.
June 6, 2018
Dominiczak J, Khansa L. Principles of Automation for Patient Safety in Intensive Care: Learning From
Aviation. Jt Comm J Qual Patient Saf. 2018;44(6):366-371. doi:10.1016/j.jcjq.2017.11.008.
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psnet.ahrq.gov/node/866813/psn-pdf
September 25, 2024 - Peer support to promote surgeon well-being: the APSA
program experience.
September 25, 2024
Fall F, Hu YY, Walker S, et al. Peer support to promote surgeon well-being: the APSA program experience.
J Pediatr Surg. 2024;59(9):1665-1671. doi:10.1016/j.jpedsurg.2023.12.022.
https://psnet.ahrq.gov/issue/peer-support-pr…
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psnet.ahrq.gov/node/60303/psn-pdf
May 06, 2020 - Using safety culture results to guide the merger of four
general practices in the UK.
May 6, 2020
Lockwood AM, Proulx J, Hill M, et al. Using safety culture results to guide the merger of four general
practices in the UK. BMJ Open Qual. 2020;9(1):e000860. doi:10.1136/bmjoq-2019-000860.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/47761/psn-pdf
May 22, 2019 - Clinicians' perceptions of opioid error–contributing
factors in inpatient palliative care services: a qualitative
study.
May 22, 2019
Heneka N, Bhattarai P, Shaw T, et al. Clinicians' perceptions of opioid error-contributing factors in inpatient
palliative care services: A qualitative study. Palliat Med. 2019;33(4…
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psnet.ahrq.gov/node/866825/psn-pdf
September 25, 2024 - Adverse Events Among In-Hospital Medicare Patients in
2021 and 2022.
September 25, 2024
Rodrick D, Timashenka A, Umscheid C. Adverse Events Among In-Hospital Medicare Patients In 2021 And
2022. Rockville, MD: Agency for Healthcare Research and Quality; 2024. AHRQ Publication no. 24-0084
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psnet.ahrq.gov/node/46190/psn-pdf
August 17, 2017 - Preventing harm in the ICU—building a culture of safety
and engaging patients and families.
August 17, 2017
Thornton KC, Schwarz JJ, Gross K, et al. Preventing Harm in the ICU-Building a Culture of Safety and
Engaging Patients and Families. Crit Care Med. 2017;45(9):1531-1537.
doi:10.1097/CCM.0000000000002556.
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psnet.ahrq.gov/node/43933/psn-pdf
March 04, 2015 - How informatics nurses use bar code technology to
reduce medication errors.
March 4, 2015
Gann M. How informatics nurses use bar code technology to reduce medication errors. Nursing (Brux).
2015;45(3):60-6. doi:10.1097/01.NURSE.0000458923.18468.37.
https://psnet.ahrq.gov/issue/how-informatics-nurses-use-bar-code-t…
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psnet.ahrq.gov/node/45041/psn-pdf
September 28, 2016 - Structure and outcomes of interdisciplinary rounds in
hospitalized medicine patients: a systematic review and
suggested taxonomy.
September 28, 2016
Bhamidipati S, Elliott DJ, Justice EM, et al. Structure and outcomes of interdisciplinary rounds in
hospitalized medicine patients: A systematic review and suggested …
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psnet.ahrq.gov/node/38091/psn-pdf
February 18, 2011 - Questionable hospital chart documentation practices by
physicians.
February 18, 2011
Sharma R, Kostis WJ, Wilson AC, et al. Questionable hospital chart documentation practices by
physicians. J Gen Intern Med. 2008;23(11):1865-70. doi:10.1007/s11606-008-0750-6.
https://psnet.ahrq.gov/issue/questionable-hospital-cha…
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psnet.ahrq.gov/node/34810/psn-pdf
February 18, 2011 - Should operations be regionalized? The empirical relation
between surgical volume and mortality.
February 18, 2011
Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The empirical relation between
surgical volume and mortality. N Engl J Med. 1979;301(25):1364-9.
https://psnet.ahrq.gov/issue/should…
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psnet.ahrq.gov/node/842415/psn-pdf
January 11, 2023 - Accuracy of spinal anesthesia drug concentrations in
mixtures prepared by anesthetists.
January 11, 2023
Heesen M, Steuer C, Wiedemeier P, et al. Accuracy of spinal anesthesia drug concentrations in mixtures
prepared by anesthetists. J Patient Saf. 2022;18(8):e1226-e1230. doi:10.1097/pts.0000000000001061.
https://…
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psnet.ahrq.gov/node/844770/psn-pdf
September 11, 2019 - Use of "Doctor" badges for physician role identification
during clinical training.
September 11, 2019
Foote MB, DeFilippis EM, Rome BN, et al. Use of "Doctor" Badges for Physician Role Identification During
Clinical Training. JAMA Intern Med. 2019. doi:10.1001/jamainternmed.2019.2416.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/74211/psn-pdf
December 22, 2021 - Filling the gaps on the Institute for Safe Medication
Practices (ISMP) Do Not Crush List for Immediate-release
Products
December 22, 2021
Uttaro E, Zhao F, Schweighardt A. Int J Pharm Compd. 2021;25(5):364-371.
https://psnet.ahrq.gov/issue/filling-gaps-institute-safe-medication-practices-ismp-do-not-crush-li…
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psnet.ahrq.gov/node/43867/psn-pdf
March 11, 2015 - Applying fault tree analysis to the prevention of wrong-
site surgery.
March 11, 2015
Abecassis ZA, McElroy LM, Patel RM, et al. Applying fault tree analysis to the prevention of wrong-site
surgery. J Surg Res. 2015;193(1):88-94. doi:10.1016/j.jss.2014.08.062.
https://psnet.ahrq.gov/issue/applying-fault-tree-analy…
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psnet.ahrq.gov/node/838920/psn-pdf
October 26, 2022 - Investigation of mental and physical health of nurses
associated with errors in clinical practice.
October 26, 2022
Pappa D, Koutelekos I, Evangelou E, et al. Investigation of mental and physical health of nurses associated
with errors in clinical practice. Healthcare (Basel). 2022;10(9):1803. doi:10.3390/healthcar…
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psnet.ahrq.gov/node/50448/psn-pdf
October 09, 2019 - Diagnostic errors reported in primary healthcare and
emergency departments: a retrospective and descriptive
cohort study of 4830 reported cases of preventable harm
in Sweden.
October 9, 2019
Fernholm R, Pukk Härenstam K, Wachtler C, et al. Diagnostic errors reported in primary healthcare and
emergency departments…
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psnet.ahrq.gov/node/837664/psn-pdf
July 13, 2022 - Cognitive and implicit biases in nurses' judgment and
decision-making: a scoping review.
July 13, 2022
Thirsk LM, Panchuk JT, Stahlke S, et al. Cognitive and implicit biases in nurses' judgment and decision-
making: a scoping review. Int J Nurs Stud. 2022;133:104284. doi:10.1016/j.ijnurstu.2022.104284.
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psnet.ahrq.gov/node/856631/psn-pdf
November 29, 2023 - Experiences and perceptions of healthcare stakeholders
in disclosing errors and adverse events to historically
marginalized patients.
November 29, 2023
Olazo K, Gallagher TH, Sarkar U. Experiences and perceptions of healthcare stakeholders in disclosing
errors and adverse events to historically marginalized patien…