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psnet.ahrq.gov/node/74042/psn-pdf
November 03, 2021 - An Investigation into the Death of Baby J at University
Hospitals Bristol and Weston NHS Foundation Trust.
November 3, 2021
Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021.
https://psnet.ahrq.gov/issue/investigation-death-baby-j-university-hospitals-bristol-and-weston-nhs-
foundation-trust…
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psnet.ahrq.gov/node/45312/psn-pdf
July 27, 2016 - Perioperative safety: learning, not taking, from aviation.
July 27, 2016
Neuhaus C, Hofer S, Hofmann G, et al. Perioperative Safety: Learning, Not Taking, from Aviation. Anesth
Analg. 2016;122(6):2059-63. doi:10.1213/ANE.0000000000001315.
https://psnet.ahrq.gov/issue/perioperative-safety-learning-not-taking-aviatio…
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psnet.ahrq.gov/node/45030/psn-pdf
November 01, 2016 - The impact of drug shortages on patients with
cardiovascular disease: causes, consequences, and a call
to action.
November 1, 2016
Reed BN, Fox ER, Konig M, et al. The impact of drug shortages on patients with cardiovascular disease:
causes, consequences, and a call to action. Am Heart J. 2016;175:130-41. doi:10.1…
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psnet.ahrq.gov/node/73922/psn-pdf
October 06, 2021 - Leading causes of anesthesia-related liability claims in
ambulatory surgery centers.
October 6, 2021
Ranum D, Beverly A, Shapiro FE, et al. Leading causes of anesthesia-related liability claims in ambulatory
surgery centers. J Patient Saf. 2021;17(7):513-521. doi:10.1097/pts.0000000000000431.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/50831/psn-pdf
January 29, 2020 - "Everybody makes mistakes": children's views on
medical errors and disclosure.
January 29, 2020
Koller D, Binder MJ, Alexander S, et al. "Everybody Makes Mistakes": Children's Views on Medical Errors
and Disclosure. J Ped Nurs. 2019;49:1-9. doi:10.1016/j.pedn.2019.07.014.
https://psnet.ahrq.gov/issue/everybody-mak…
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psnet.ahrq.gov/node/37120/psn-pdf
March 24, 2011 - Patient safety culture in primary care: developing a
theoretical framework for practical use.
March 24, 2011
Kirk S, Parker D, Claridge T, et al. Patient safety culture in primary care: developing a theoretical
framework for practical use. Qual Saf Health Care. 2007;16(4):313-20.
https://psnet.ahrq.gov/issue/patie…
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psnet.ahrq.gov/node/61126/psn-pdf
November 11, 2020 - Potential for false positive results with antigen tests for
rapid detection of SARS-CoV-2--letter to clinical
laboratory staff and health care providers.
November 11, 2020
US Food and Drug Administration: November 3, 2020.
https://psnet.ahrq.gov/issue/potential-false-positive-results-antigen-tests-rapid-detection-…
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psnet.ahrq.gov/node/41624/psn-pdf
November 06, 2012 - How nurses and physicians judge their own quality of
care for deteriorating patients on medical wards: self-
assessment of quality of care is suboptimal.
November 6, 2012
Ludikhuize J, Dongelmans DA, Smorenburg SM, et al. How nurses and physicians judge their own quality
of care for deteriorating patients on medic…
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psnet.ahrq.gov/node/43726/psn-pdf
September 01, 2016 - Differences of reasons for alert overrides on
contraindicated co-prescriptions by admitting
department.
September 1, 2016
Ahn EK, Cho S-Y, Shin D, et al. Differences of Reasons for Alert Overrides on Contraindicated Co-
prescriptions by Admitting Department. Healthc Inform Res. 2014;20(4):280-7.
doi:10.4258/hir.2…
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psnet.ahrq.gov/node/35740/psn-pdf
May 27, 2011 - Impact of computerized physician order entry on
medication prescription errors in the intensive care unit: a
controlled cross-sectional trial.
May 27, 2011
Colpaert K, Claus B, Somers A, et al. Impact of computerized physician order entry on medication
prescription errors in the intensive care unit: a controlled c…
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psnet.ahrq.gov/node/35374/psn-pdf
January 02, 2017 - Intimidation: practitioners speak up about this unresolved
problem.
January 2, 2017
Smetzer JL, Cohen MR. Intimidation: Practitioners Speak Up About This Unresolved Problem. Jt Comm J
Qual Patient Saf. 2016;31(10):594-599. doi:10.1016/s1553-7250(05)31077-4.
https://psnet.ahrq.gov/issue/intimidation-practitioners-s…
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psnet.ahrq.gov/node/46564/psn-pdf
December 06, 2017 - Can the aviation industry be useful in teaching oncology
about safety?
December 6, 2017
Davies JM, Delaney G. Can the Aviation Industry be Useful in Teaching Oncology about Safety? Clin Oncol
(R Coll Radiol). 2017;29(10):669-675. doi:10.1016/j.clon.2017.06.007.
https://psnet.ahrq.gov/issue/can-aviation-industry-be…
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psnet.ahrq.gov/node/35553/psn-pdf
July 03, 2013 - Maximizing the Use of State Adverse Event Data to
Improve Patient Safety.
July 3, 2013
Rosenthal J, Booth M. National Academy for State Health Policy; 2005.
https://psnet.ahrq.gov/issue/maximizing-use-state-adverse-event-data-improve-patient-safety
This report, generated by the National Academy for State Health Po…
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psnet.ahrq.gov/node/862153/psn-pdf
February 07, 2024 - Anticipating patient safety events in psychiatric care.
February 7, 2024
Yerstein MC, SUNDARARAJ DEEPIKA, McClean M, et al. Anticipating patient safety events in psychiatric
care. J Psychiatr Pract. 2024;30(1):68-72. doi:10.1097/pra.0000000000000760.
https://psnet.ahrq.gov/issue/anticipating-patient-safety-events-p…
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psnet.ahrq.gov/node/35127/psn-pdf
February 24, 2011 - Beyond the medical record: other modes of error
acknowledgment.
February 24, 2011
Rosenthal M, Cornett PL, Sutcliffe K, et al. Beyond the medical record: other modes of error
acknowledgment. J Gen Intern Med. 2005;20(5):404-9.
https://psnet.ahrq.gov/issue/beyond-medical-record-other-modes-error-acknowledgment
Thi…
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psnet.ahrq.gov/node/40976/psn-pdf
February 20, 2012 - Patient safety in patients who occupy beds on clinically
inappropriate wards: a qualitative interview study with
NHS staff.
February 20, 2012
Goulding L, Adamson J, Watt I, et al. Patient safety in patients who occupy beds on clinically inappropriate
wards: a qualitative interview study with NHS staff. BMJ Qual Sa…
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psnet.ahrq.gov/node/44764/psn-pdf
February 10, 2016 - Human factors—recognising and minimising errors in our
day to day practice.
February 10, 2016
Green B, Tsiroyannis C, Brennan PA. Human factors--recognising and minimising errors in our day to day
practice. Oral Dis. 2016;22(1):19-22. doi:10.1111/odi.12384.
https://psnet.ahrq.gov/issue/human-factors-recognising-an…
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psnet.ahrq.gov/node/41169/psn-pdf
May 19, 2014 - Risk factors for patient-reported medical errors in eleven
countries.
May 19, 2014
Schwappach DLB. Risk factors for patient-reported medical errors in eleven countries. Health Expect.
2014;17(3):321-31. doi:10.1111/j.1369-7625.2011.00755.x.
https://psnet.ahrq.gov/issue/risk-factors-patient-reported-medical-errors-…
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psnet.ahrq.gov/node/41894/psn-pdf
January 01, 2016 - Simulator-based crew resource management training for
interhospital transfer of critically ill patients by a mobile
ICU.
January 9, 2013
Droogh JM, Kruger HL, Ligtenberg JJM, et al. Simulator-Based Crew Resource Management Training for
Interhospital Transfer of Critically Ill Patients by a Mobile ICU. Jt Comm J Qu…
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psnet.ahrq.gov/node/44895/psn-pdf
March 09, 2016 - On patient safety: when are we too old to operate?
March 9, 2016
Lee MJ. On Patient Safety: When Are We Too Old to Operate? Clin Orthop Relat Res. 2016;474(4):895-8.
doi:10.1007/s11999-016-4722-6.
https://psnet.ahrq.gov/issue/patient-safety-when-are-we-too-old-operate
High-risk industries often have mandatory requ…