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psnet.ahrq.gov/node/836915/psn-pdf
April 13, 2022 - Workarounds in electronic health record systems and the
revised Sociotechnical Electronic Health Record
Workaround Analysis Framework: scoping review.
April 13, 2022
Blijleven V, Hoxha F, Jaspers MWM. Workarounds in electronic health record systems and the revised
sociotechnical Electronic Health Record workaround…
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psnet.ahrq.gov/node/837730/psn-pdf
January 01, 2023 - Factors influencing medication errors in the prehospital
paramedic environment: a mixed method systematic
review.
July 28, 2022
Walker D, Moloney C, SueSee B, et al. Factors influencing medication errors in the prehospital paramedic
environment: a mixed method systematic review. Prehosp Emerg Care. 2023;27(5):669-…
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psnet.ahrq.gov/node/47385/psn-pdf
April 27, 2019 - Reasons for repeat rapid response team calls, and
associations with in-hospital mortality.
April 27, 2019
Chalwin R, Giles L, Salter A, et al. Reasons for Repeat Rapid Response Team Calls, and Associations with
In-Hospital Mortality. Jt Comm J Qual Patient Saf. 2019;45(4):268-275. doi:10.1016/j.jcjq.2018.10.005.
h…
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psnet.ahrq.gov/node/849600/psn-pdf
May 31, 2023 - Danger in discharge summaries: abbreviations create
confusion for both author and recipient.
May 31, 2023
Coghlan A, Turner S, Coverdale S. Danger in discharge summaries: abbreviations create confusion for
both author and recipient. Intern Med J. 2023;53(4):550-558. doi:10.1111/imj.15582.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/45596/psn-pdf
January 09, 2018 - More holes than cheese. What prevents the delivery of
effective, high quality, and safe healthcare in England?
January 9, 2018
Hignett S, Lang A, Pickup L, et al. More holes than cheese. What prevents the delivery of effective, high
quality and safe health care in England? Ergonomics. 2018;61(1):5-14.
doi:10.1080/…
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psnet.ahrq.gov/node/839319/psn-pdf
November 02, 2022 - Improving safety in the operating room: medication icon
labels increase visibility and discrimination.
November 2, 2022
Lusk C, Catchpole K, Neyens DM, et al. Improving safety in the operating room: medication icon labels
increase visibility and discrimination. Appl Ergon. 2022;104:103831. doi:10.1016/j.apergo.2022…
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psnet.ahrq.gov/node/46372/psn-pdf
September 13, 2017 - Impact of a successful speaking up program on health-
care worker hand hygiene behavior.
September 13, 2017
Linam MW; Honeycutt MD; Gilliam CH; Wisdom CM; Deshpande JK.
https://psnet.ahrq.gov/issue/impact-successful-speaking-program-health-care-worker-hand-hygiene-
behavior
Improving hand hygiene in health care f…
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psnet.ahrq.gov/node/45085/psn-pdf
May 04, 2016 - A piece of my mind. The patient you least want to see.
May 4, 2016
Chen JH. A PIECE OF MY MIND. The Patient You Least Want to See. JAMA. 2016;315(16):1701-2.
doi:10.1001/jama.2016.0221.
https://psnet.ahrq.gov/issue/piece-my-mind-patient-you-least-want-see
Providing insights from a physician regarding the complexit…
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psnet.ahrq.gov/node/72639/psn-pdf
January 13, 2021 - Assessment of physician sleep and wellness, burnout,
and clinically significant medical errors.
January 13, 2021
Trockel MT, Menon NK, Rowe SG, et al. Assessment of Physician Sleep and Wellness, Burnout, and
Clinically Significant Medical Errors. JAMA Netw Open. 2020;3(12):e2028111.
doi:10.1001/jamanetworkopen.202…
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psnet.ahrq.gov/node/34795/psn-pdf
December 23, 2008 - Preventable adverse drug events in hospitalized patients:
a comparative study of intensive care and general care
units.
December 23, 2008
Cullen DJ, Sweitzer BJ, Bates DW, et al. Preventable adverse drug events in hospitalized patients. Crit
Care Med. 1997;25(8):1289-1297. doi:10.1097/00003246-199708000-00014.
ht…
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psnet.ahrq.gov/node/836747/psn-pdf
March 16, 2022 - Patient perceptions of hospital experiences: implications
for innovations in patient safety.
March 16, 2022
Butler JM, Gibson B, Schnock KO, et al. Patient perceptions of hospital experiences: implications for
innovations in patient safety. J Patient Saf. 2022;18(2):e563-e567. doi:10.1097/pts.0000000000000865.
htt…
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psnet.ahrq.gov/node/73217/psn-pdf
May 05, 2021 - Assessing patients 2019 experiences with medical injury
reconciliation processes: item generation for a novel
survey questionnaire.
May 5, 2021
Schulz-Moore JS, Bismark M, Jenkinson C, et al. Assessing patients 2019 experiences with medical injury
reconciliation processes: item generation for a novel survey questi…
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psnet.ahrq.gov/node/38697/psn-pdf
June 10, 2009 - A report card system using error profile analysis and
concurrent morbidity and mortality review: surgical
outcome analysis, part II.
June 10, 2009
Antonacci AC, Lam S, Lavarias V, et al. A report card system using error profile analysis and concurrent
morbidity and mortality review: surgical outcome analysis, part…
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psnet.ahrq.gov/node/44616/psn-pdf
November 04, 2015 - Development of "SWARM" as a model for high reliability,
rapid problem solving, and institutional learning.
November 4, 2015
Williams EA, Nikolai DA, Ladwig L, et al. Development of "SWARM" as a Model for High Reliability, Rapid
Problem Solving, and Institutional Learning. Jt Comm J Qual Patient Saf. 2015;41(11):508…
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psnet.ahrq.gov/node/46300/psn-pdf
August 16, 2017 - Prioritizing medication safety in care of people with
cancer: clinicians' views on main problems and solutions.
August 16, 2017
Car LT, Papachristou N, Urch C, et al. Prioritizing medication safety in care of people with cancer:
clinicians' views on main problems and solutions. J Glob Health. 2017;7(1):011001.
doi…
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psnet.ahrq.gov/node/60816/psn-pdf
August 19, 2020 - Workplace verbal abuse, nurse-reported quality of care,
and patient safety outcomes among early-career hospital
nurses.
August 19, 2020
Cho H, Pavek K, Steege LM. Workplace verbal abuse, nurse?reported quality of care and patient safety
outcomes among early?career hospital nurses. J Nurs Manag. 2020;28(6):1250-125…
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psnet.ahrq.gov/node/867390/psn-pdf
December 18, 2024 - Quality of care and quality of life: balancing patient safety
and physician burnout.
December 18, 2024
Minkoff H, O'Brien J, Berkowitz R. Quality of care and quality of life: balancing patient safety and physician
burnout. Obstet Gynecol. 2024;144(3):e50-e55. doi:10.1097/aog.0000000000005681.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/44089/psn-pdf
April 22, 2015 - Learning from mistakes and near mistakes: using root
cause analysis as a risk management tool.
April 22, 2015
Cerniglia-Lowensen J. Learning From Mistakes and Near Mistakes: Using Root Cause Analysis as a Risk
Management Tool. J Radiol Nurs. 2015;34(1). doi:10.1016/j.jradnu.2014.11.004.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/34843/psn-pdf
March 02, 2011 - Hand hygiene among physicians: performance, beliefs,
and perceptions.
March 2, 2011
Pittet D, Simon A, Hugonnet S, et al. Hand hygiene among physicians: performance, beliefs, and
perceptions. Ann Intern Med. 2004;141(1):1-8.
https://psnet.ahrq.gov/issue/hand-hygiene-among-physicians-performance-beliefs-and-percept…
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psnet.ahrq.gov/node/39872/psn-pdf
February 25, 2013 - The Essential Guide for Patient Safety Officers, Second
Edition.
February 25, 2013
Leonard M, Frankel A, Federico F, et al, eds. Oakbrook Terrace, IL: Joint Commission Resources, Institute
for Healthcare Improvement; 2013. ISBN: 9781599407036.
https://psnet.ahrq.gov/issue/essential-guide-patient-safety-officers-se…