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psnet.ahrq.gov/primer/detection-safety-hazards
March 30, 2022 - Detection of Safety Hazards
Citation Text:
Detection of Safety Hazards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/not-miscarriage
June 01, 2005 - Not a Miscarriage
Citation Text:
Learman LA. Not a Miscarriage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/issue/check-your-medicines-tips-taking-medicines-safely
September 04, 2018 - Government Resource
Check Your Medicines: Tips for Taking Medicines Safely.
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April 23, 2012
This 5-point checklist provides consu…
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psnet.ahrq.gov/node/38504/psn-pdf
September 06, 2011 - Safe Practices for Better Healthcare–2009 Update.
September 6, 2011
National Quality Forum. Washington, DC: National Quality Forum; 2009.
https://psnet.ahrq.gov/issue/safe-practices-better-healthcare-2009-update
The National Quality Forum's Safe Practices for Better Healthcare provide a blueprint for organizations …
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psnet.ahrq.gov/node/35617/psn-pdf
January 01, 2016 - Reconciling medications at admission: safe practice
recommendations and implementation strategies.
June 13, 2011
Rogers G, Alper E, Brunelle D, et al. Reconciling Medications at Admission: Safe Practice
Recommendations and Implementation Strategies. Jt Comm J Qual Patient Saf. 2016;32(1):37-50.
doi:10.1016/s1553-7…
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psnet.ahrq.gov/node/42503/psn-pdf
September 18, 2013 - The patient is in: patient involvement strategies for
diagnostic error mitigation.
September 18, 2013
McDonald KM, Bryce CL, Graber ML. The patient is in: patient involvement strategies for diagnostic error
mitigation. BMJ Qual Saf. 2013;22 Suppl 2:ii33-ii39. doi:10.1136/bmjqs-2012-001623.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/47590/psn-pdf
February 20, 2019 - Explaining organisational responses to a board-level
quality improvement intervention: findings from an
evaluation in six providers in the English National Health
Service.
February 20, 2019
Jones L, Pomeroy L, Robert G, et al. Explaining organisational responses to a board-level quality
improvement intervention: …
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psnet.ahrq.gov/node/855434/psn-pdf
January 22, 2022 - A risk science perspective on the discussion concerning
Safety I, Safety II and Safety III.
January 22, 2022
Aven T. A risk science perspective on the discussion concerning Safety I, Safety II and Safety III. Reliability
Eng System Saf. 2022;217:108077. doi:10.1016/j.ress.2021.108077.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/867685/psn-pdf
March 05, 2025 - Understanding factors influencing safety and team
functionality at operative vaginal birth through
multidisciplinary perspectives: a mixed methods study.
March 5, 2025
Skinner SM, Kippen E, Rolnik DL, et al. Understanding factors influencing safety and team functionality at
operative vaginal birth through multidis…
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psnet.ahrq.gov/node/73856/psn-pdf
September 22, 2021 - Implicit bias and caring for diverse populations: pediatric
trainee attitudes and gaps in training.
September 22, 2021
Barber Doucet H, Ward VL, Johnson TJ, et al. Implicit bias and caring for diverse populations: pediatric
trainee attitudes and gaps in training. Clin Pediatr (Phila). 2021;60(9-10):408-417.
doi:10…
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psnet.ahrq.gov/node/73538/psn-pdf
July 28, 2021 - Physician use of stigmatizing language in patient medical
records.
July 28, 2021
Park J, Saha S, Chee B, et al. Physician use of stigmatizing language in patient medical records. JAMA
Netw Open. 2021;4(7):e2117052. doi:10.1001/jamanetworkopen.2021.17052.
https://psnet.ahrq.gov/issue/physician-use-stigmatizing-lang…
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psnet.ahrq.gov/node/39692/psn-pdf
July 21, 2010 - An unintended consequence of electronic prescriptions:
prevalence and impact of internal discrepancies.
July 21, 2010
Palchuk MB, Fang EA, Cygielnik JM, et al. An unintended consequence of electronic prescriptions:
prevalence and impact of internal discrepancies. J Am Med Inform Assoc. 2010;17(4):472-6.
doi:10.113…
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psnet.ahrq.gov/node/44949/psn-pdf
February 01, 2019 - Detecting and treating suicide ideation in all settings.
December 23, 2016
Detecting and treating suicide ideation in all settings. Sentinel event alert. 2016;(56):1-7.
https://psnet.ahrq.gov/issue/detecting-and-treating-suicide-ideation-all-settings
The Joint Commission publishes sentinel event alerts to emphasize…
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psnet.ahrq.gov/node/851912/psn-pdf
August 02, 2023 - Fatigue amongst anaesthesiology and intensive care
trainees in Europe: a matter of concern.
August 2, 2023
Abramovich I, Matias B, Norte G, et al. Fatigue amongst anaesthesiology and intensive care trainees in
Europe: a matter of concern. Eur J Anaesthesiol. 2023;40(8):587-595. doi:10.1097/eja.0000000000001849.
ht…
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psnet.ahrq.gov/node/34653/psn-pdf
March 07, 2005 - Structural and organizational issues in patient safety: a
comparison of health care to other high-hazard
industries.
March 7, 2005
Gaba DM. California Manage Rev. 2000;43(1):83-102.
https://psnet.ahrq.gov/issue/structural-and-organizational-issues-patient-safety-comparison-health-care-
other-high-hazard
Gaba ana…
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psnet.ahrq.gov/node/45680/psn-pdf
February 22, 2017 - Pediatric medication safety in adult community hospital
settings: a glimpse into nationwide practice.
February 22, 2017
Alvarez F, Ismail L, Markowsky A. Pediatric Medication Safety in Adult Community Hospital Settings: A
Glimpse Into Nationwide Practice. Hosp Pediatr. 2016;6(12):744-749.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/47911/psn-pdf
April 03, 2019 - Second victims need emotional support after adverse
events: even in a just safety culture.
April 3, 2019
Schrøder K, Lamont RF, Jørgensen JS, et al. Second victims need emotional support after adverse events:
even in a just safety culture. BJOG. 2019;126(4):440-442. doi:10.1111/1471-0528.15529.
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psnet.ahrq.gov/issue/sorry-works
November 15, 2024 - Multi-use Website
Sorry Works!
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March 17, 2011
Sorry Works! supports a full-disclosure approach to medical errors. They encourage…
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psnet.ahrq.gov/node/72523/psn-pdf
December 02, 2020 - Clinical decision support improves the appropriateness of
laboratory test ordering in primary care without
increasing diagnostic error: the ELMO cluster randomized
trial.
December 2, 2020
Delvaux N, Piessens V, Burghgraeve TD, et al. Clinical decision support improves the appropriateness of
laboratory test orderi…
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psnet.ahrq.gov/node/73440/psn-pdf
June 30, 2021 - Bridging the feedback gap: a sociotechnical approach to
informing clinicians of patients' subsequent clinical
course and outcomes.
June 30, 2021
Cifra CL, Sittig DF, Singh H. Bridging the feedback gap: a sociotechnical approach to informing clinicians of
patients’ subsequent clinical course and outcomes. BMJ Qual …