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psnet.ahrq.gov/node/37556/psn-pdf
November 21, 2016 - Unexpected intraoperative patient death: the imperatives
of family- and surgeon-centered care.
November 21, 2016
Taylor D, Hassan MA, Luterman A, et al. Unexpected intraoperative patient death: the imperatives of
family- and surgeon-centered care. Arch Surg. 2008;143(1):87-92. doi:10.1001/archsurg.2007.27.
https:/…
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psnet.ahrq.gov/node/35158/psn-pdf
January 02, 2017 - Using simulation-based training to improve patient safety:
what does it take?
January 2, 2017
Salas E, Wilson K, Burke S, et al. Using simulation-based training to improve patient safety: what does it
take? Jt Comm J Qual Patient Saf. 2005;31(7):363-71.
https://psnet.ahrq.gov/issue/using-simulation-based-training-…
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psnet.ahrq.gov/node/39698/psn-pdf
July 21, 2010 - Preventing catheter-related bloodstream infections
outside the intensive care unit: expanding prevention to
new settings.
July 21, 2010
Kallen AJ, Patel PR, O'Grady NP. Preventing catheter-related bloodstream infections outside the intensive
care unit: expanding prevention to new settings. Clin Infect Dis. 2010;51…
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psnet.ahrq.gov/node/47978/psn-pdf
May 01, 2019 - Patient Safety.
May 1, 2019
GMS J Med Educ. 2019;36:Doc11-Doc22.
https://psnet.ahrq.gov/issue/patient-safety-16
Patient safety has been described as an unmet need in physician training. This special issue covers areas
of focus for a patient safety curriculum drawn from experience in the German medical education sy…
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psnet.ahrq.gov/node/866567/psn-pdf
August 21, 2024 - A daily dose of communication to improve quality and
safety outcomes.
August 21, 2024
Halm MA. A daily dose of communication to improve quality and safety outcomes. Am J Crit Care.
2024;33(4):305-310. doi:10.4037/ajcc2024318.
https://psnet.ahrq.gov/issue/daily-dose-communication-improve-quality-and-safety-outcomes…
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psnet.ahrq.gov/node/36225/psn-pdf
July 10, 2008 - Transfers of patient care between house staff on internal
medicine wards: a national survey.
July 10, 2008
Horwitz LI, Krumholz HM, Green M, et al. Transfers of patient care between house staff on internal
medicine wards: a national survey. Arch Intern Med. 2006;166(11):1173-7.
https://psnet.ahrq.gov/issue/transfe…
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psnet.ahrq.gov/node/37861/psn-pdf
June 25, 2008 - Adverse outcomes of blood transfusion in children:
analysis of UK reports to the serious hazards of
transfusion scheme 1996-2005.
June 25, 2008
Stainsby D, Jones H, Wells AW, et al. Adverse outcomes of blood transfusion in children: analysis of UK
reports to the serious hazards of transfusion scheme 1996-2005. Br …
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psnet.ahrq.gov/node/39265/psn-pdf
February 03, 2010 - Intensive care unit alarms—how many do we need?
February 3, 2010
Siebig S, Kuhls S, Imhoff M, et al. Intensive care unit alarms--how many do we need? Crit Care Med.
2010;38(2):451-6. doi:10.1097/CCM.0b013e3181cb0888.
https://psnet.ahrq.gov/issue/intensive-care-unit-alarms-how-many-do-we-need
This study found that …
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psnet.ahrq.gov/node/838085/psn-pdf
September 14, 2022 - Administering High-Strength Insulin from a Pen Device in
Hospital.
September 14, 2022
Farnborough, UK: Healthcare Safety Investigation Branch; July 7, 2022.
https://psnet.ahrq.gov/issue/administering-high-strength-insulin-pen-device-hospital
Misuse of insulin pens contributes to never events associated with diabet…
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psnet.ahrq.gov/node/46198/psn-pdf
August 16, 2017 - Challenging authority during an emergency—the effect of
a teaching intervention.
August 16, 2017
Friedman Z, Perelman V, McLuckie D, et al. Challenging Authority During an Emergency-the Effect of a
Teaching Intervention. Crit Care Med. 2017;45(8):e814-e820. doi:10.1097/CCM.0000000000002450.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/41072/psn-pdf
January 18, 2012 - Improving medication management through the redesign
of the hospital code cart medication drawer.
January 18, 2012
Rousek JB, Hallbeck MS. Improving Medication Management Through the Redesign of the Hospital Code
Cart Medication Drawer. Human Factors: The Journal of the Human Factors and Ergonomics Society.
2011;5…
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psnet.ahrq.gov/node/865597/psn-pdf
April 17, 2024 - Discharge from Mental Health Care: Making it Safe and
Patient-centred.
April 17, 2024
Manchester, UK: Parliamentary and Health Service Ombudsman; March 2024.
https://psnet.ahrq.gov/issue/discharge-mental-health-care-making-it-safe-and-patient-centred
The provision of safe mental health care is receiving increased …
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psnet.ahrq.gov/node/838636/psn-pdf
October 19, 2022 - A qualitative survey of factors shaping the role of a safety
professional.
October 19, 2022
Van Wassenhove W, Foussard C, Dekker SWA, et al. A qualitative survey of factors shaping the role of a
safety professional. Safety Sci. 2022;154:105835. doi:10.1016/j.ssci.2022.105835.
https://psnet.ahrq.gov/issue/qualitati…
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psnet.ahrq.gov/node/38385/psn-pdf
February 04, 2009 - Impact of a computerized physician order entry system
on nurse-physician collaboration in the medication
process.
February 4, 2009
Pirnejad H, Niazkhani Z, van der Sijs H, et al. Impact of a computerized physician order entry system on
nurse-physician collaboration in the medication process. Int J Med Inform. 2008…
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psnet.ahrq.gov/node/43084/psn-pdf
May 19, 2014 - How can the criminal law support the provision of quality
in healthcare?
May 19, 2014
Yeung K, Horder J. How can the criminal law support the provision of quality in healthcare? BMJ Qual Saf.
2014;23(6):519-24. doi:10.1136/bmjqs-2013-002688.
https://psnet.ahrq.gov/issue/how-can-criminal-law-support-provision-quali…
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psnet.ahrq.gov/node/41436/psn-pdf
October 19, 2012 - Which clinical errors lead to the referral of UK
paediatricians to the National Clinical Assessment
Service?
October 19, 2012
Raine J, Scarrott D. Which clinical errors lead to the referral of UK paediatricians to the National Clinical
Assessment Service? Eur J Pediatr. 2012;171(10):1449-52.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/44649/psn-pdf
November 11, 2015 - Seven (potentially) deadly prescribing errors.
November 11, 2015
Graham LR, Scudder L, Stokowski L. Medscape. October 22, 2015.
https://psnet.ahrq.gov/issue/seven-potentially-deadly-prescribing-errors
Errors in the prescribing process can lead to adverse drug events. This slide set provides information about
commo…
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psnet.ahrq.gov/node/46838/psn-pdf
March 07, 2018 - Behavioral & Mental Health Toolbox.
March 7, 2018
Center for Health Design. Concord, CA: Center for Health Design; 2018.
https://psnet.ahrq.gov/issue/behavioral-mental-health-toolbox
Behavioral and mental health patients have unique concerns that affect their safety. This toolkit provides
strategies, insights, and…
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psnet.ahrq.gov/node/37117/psn-pdf
October 04, 2011 - Language barriers to prescriptions for patients with
limited English proficiency: a survey of pharmacies.
October 4, 2011
Bradshaw M, Tomany-Korman S, Flores G. Language barriers to prescriptions for patients with limited
English proficiency: a survey of pharmacies. Pediatrics. 2007;120(2):e225-35.
https://psnet.a…
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psnet.ahrq.gov/node/60951/psn-pdf
September 23, 2020 - A Guide to Patient Safety Improvement: Integrating
Knowledge Translation & Quality Improvement
Approaches.
September 23, 2020
Edmonton, Alberta; Canadian Patient Safety Institute: 2020. ISBN: 9781926541846.
https://psnet.ahrq.gov/issue/guide-patient-safety-improvement-integrating-knowledge-translation-quality-
im…