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psnet.ahrq.gov/node/866818/psn-pdf
September 25, 2024 - Academic half day improves resident perception of
education without compromising patient safety.
September 25, 2024
Spence MC, Sugarman A, Uong A, et al. Academic half day improves resident perception of education
without compromising patient safety. Acad Pediatr. 2024;24(6):1010-1016. doi:10.1016/j.acap.2024.02.00…
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psnet.ahrq.gov/node/44047/psn-pdf
September 09, 2015 - Linking acknowledgement to action: closing the loop on
non-urgent, clinically significant test results in the
electronic health record.
September 9, 2015
Dalal A, Pesterev BM, Eibensteiner K, et al. Linking acknowledgement to action: closing the loop on non-
urgent, clinically significant test results in the elect…
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psnet.ahrq.gov/node/867192/psn-pdf
November 20, 2024 - 2024 Network of Patient Safety Databases Chartbook:
Medication and Other Substance Events.
November 20, 2024
2024 Network Of Patient Safety Databases Chartbook: Medication And Other Substance Events. Rockville,
MD: Agency for Healthcare Research and Quality; 2024. AHRQ Pub. No. 24-0088
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/60352/psn-pdf
January 01, 2021 - Stakeholders in safety: patient reports on unsafe clinical
behaviors distinguish hospital mortality rates.
May 20, 2020
Reader TW, Gillespie A. Stakeholders in safety: patient reports on unsafe clinical behaviors distinguish
hospital mortality rates. J Appl Psychol. 2021;106(3):439-451. doi:10.1037/apl0000507.
htt…
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psnet.ahrq.gov/node/46999/psn-pdf
June 27, 2018 - Empowering patients and agents to help prevent errors
with living wills, DNRs, and POLSTs.
June 27, 2018
Hoffman RM, Mirarchi FL. PA-PSRS Patient Saf Advis. June 2018;15.
https://psnet.ahrq.gov/issue/empowering-patients-and-agents-help-prevent-errors-living-wills-dnrs-and-
polsts
Patient harm associated with adva…
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psnet.ahrq.gov/node/45855/psn-pdf
March 15, 2017 - The development and implementation of cognitive aids
for critical events in pediatric anesthesia: the Society for
Pediatric Anesthesia Critical Events Checklists.
March 15, 2017
Clebone A, Burian BK, Watkins SC, et al. The Development and Implementation of Cognitive Aids for
Critical Events in Pediatric Anesthesia…
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psnet.ahrq.gov/node/34767/psn-pdf
November 28, 2018 - Why Things Bite Back: Technology and the Revenge of
Unintended Consequences.
November 28, 2018
Tenner E. New York, NY: Knopf; 1996. ISBN: 0679425632.
https://psnet.ahrq.gov/issue/why-things-bite-back-technology-and-revenge-unintended-consequences
Tenner’s discussions of medical and nonmedical examples provide an e…
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psnet.ahrq.gov/node/44864/psn-pdf
March 23, 2016 - Caught in the middle: a resident perspective on
influences from the learning environment that perpetuate
mistreatment.
March 23, 2016
Bynum WE, Lindeman B. Caught in the Middle: A Resident Perspective on Influences From the Learning
Environment That Perpetuate Mistreatment. Acad Med. 2016;91(3):301-4.
doi:10.1097…
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psnet.ahrq.gov/node/45074/psn-pdf
June 01, 2016 - Post-event debriefings during neonatal care: why are we
not doing them, and how can we start?
June 1, 2016
Sawyer T, Loren D, Halamek LP. Post-event debriefings during neonatal care: why are we not doing them,
and how can we start? J Perinatol. 2016;36(6):415-9. doi:10.1038/jp.2016.42.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/45683/psn-pdf
January 23, 2017 - Consensus bundle on prevention of surgical site
infections after major gynecologic surgery.
January 23, 2017
Pellegrini JE, Toledo P, Soper DE, et al. Consensus Bundle on Prevention of Surgical Site Infections After
Major Gynecologic Surgery. Obstet Gynecol. 2017;129(1):50-61. doi:10.1097/AOG.0000000000001751.
htt…
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psnet.ahrq.gov/node/36784/psn-pdf
February 24, 2011 - The many faces of error disclosure: a common set of
elements and a definition.
February 24, 2011
Fein SP, Hilborne LH, Spiritus EM, et al. The many faces of error disclosure: a common set of elements
and a definition. J Gen Intern Med. 2007;22(6):755-761.
https://psnet.ahrq.gov/issue/many-faces-error-disclosure-co…
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psnet.ahrq.gov/node/837899/psn-pdf
August 24, 2022 - Feelings of trust and of safety are related facets of the
patient's experience in surgery: a descriptive qualitative
study in 80 patients.
August 24, 2022
Occelli P, Mougeot F, Robelet M, et al. Feelings of trust and of safety are related facets of the patient's
experience in surgery: a descriptive qualitative stu…
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psnet.ahrq.gov/node/852271/psn-pdf
August 09, 2023 - Redesign of health care systems to reduce diagnostic
errors: leveraging human experience and artificial
intelligence.
August 9, 2023
Abid MH. Redesign of health care systems to reduce diagnostic errors: leveraging human experience and
artificial intelligence. J Clin Outcomes Manag. 2023;30(3):67-70. doi:10.12788/j…
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psnet.ahrq.gov/node/43543/psn-pdf
November 05, 2014 - A patient safety approach to setting pass/fail standards
for basic procedural skills checklists.
November 5, 2014
Yudkowsky R, Tumuluru S, Casey P, et al. A patient safety approach to setting pass/fail standards for basic
procedural skills checklists. Simul Healthc. 2014;9(5):277-82. doi:10.1097/SIH.000000000000004…
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psnet.ahrq.gov/node/45152/psn-pdf
November 18, 2016 - Department of Veterans Affairs Chief Resident in Quality
and Patient Safety Program: a model to spread change.
November 18, 2016
Watts B, Paull DE, Williams LC, et al. Department of Veterans Affairs Chief Resident in Quality and Patient
Safety Program: A Model to Spread Change. Am J Med Qual. 2016;31(6):598-600.
h…
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psnet.ahrq.gov/node/860728/psn-pdf
January 17, 2024 - Factors influencing second victim experiences and
support needs of OB/GYN and pediatric healthcare
professionals after adverse patient events.
January 17, 2024
Rivera-Chiauzzi EY, Riggan KA, Huang L, et al. Factors influencing second victim experiences and support
needs of OB/GYN and pediatric healthcare professio…
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psnet.ahrq.gov/node/44884/psn-pdf
February 17, 2016 - Changes in default alarm settings and standard in-service
are insufficient to improve alarm fatigue in an intensive
care unit: a pilot project.
February 17, 2016
Sowan AK, Gomez TM, Tarriela AF, et al. Changes in Default Alarm Settings and Standard In-Service are
Insufficient to Improve Alarm Fatigue in an Intensi…
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psnet.ahrq.gov/node/867011/psn-pdf
October 23, 2024 - Outcomes of Michigan Medicine's integrated patient
safety and communication and resolution program,
2013–2022.
October 23, 2024
Burney RE, Mckeown ES, Zhang Y, et al. Outcomes of Michigan Medicine's integrated patient safety and
communication and resolution program, 2013–2022. J Patient Saf Risk Manag. 2024;29(5):…
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psnet.ahrq.gov/node/864378/psn-pdf
March 13, 2024 - Investigating workplace support and the importance of
psychological safety in general surgery residency
training.
March 13, 2024
Ojute F, Gonzales PA, Berler M, et al. Investigating workplace support and the importance of psychological
safety in general surgery residency training. J Surg Educ. 2024;81(4):514-524.
…
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psnet.ahrq.gov/node/47077/psn-pdf
May 23, 2018 - World Health Organization-World Federation of Societies
of Anaesthesiologists (WHO-WFSA) International
Standards for a Safe Practice of Anesthesia.
May 23, 2018
Gelb AW, Morriss WW, Johnson W, et al. World Health Organization-World Federation of Societies of
Anaesthesiologists (WHO-WFSA) International Standards fo…