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psnet.ahrq.gov/node/43423/psn-pdf
August 12, 2014 - Deafening silence? Time to reconsider whether
organisations are silent or deaf when things go wrong.
August 12, 2014
Jones A, Kelly D. Deafening silence? Time to reconsider whether organisations are silent or deaf when
things go wrong. BMJ Qual Saf. 2014;23(9):709-13. doi:10.1136/bmjqs-2013-002718.
https://psnet.a…
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psnet.ahrq.gov/node/45845/psn-pdf
December 19, 2017 - You can't blame the wreck on the train.
December 19, 2017
Potts JR. You can't blame the wreck on the train. Am J Surg. 2017;214(5):974-978.
doi:10.1016/j.amjsurg.2016.11.046.
https://psnet.ahrq.gov/issue/you-cant-blame-wreck-train
Insufficient supervision can limit resident education, which may increase risks to p…
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psnet.ahrq.gov/node/866957/psn-pdf
October 16, 2024 - Pharmacy prevalence of second victim syndrome in a
comprehensive cancer center.
October 16, 2024
Johnson TN, Tucker AM. Pharmacy prevalence of second victim syndrome in a comprehensive cancer
center. Am J Health-Syst Pharm. 2024;Epub Sep 13. doi:10.1093/ajhp/zxae267.
https://psnet.ahrq.gov/issue/pharmacy-prevalenc…
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psnet.ahrq.gov/node/60960/psn-pdf
September 30, 2020 - COVID-19 pandemic preparation: using simulation for
systems-based learning to prepare the largest healthcare
workforce and system in Canada.
September 30, 2020
Dubé MM, Kaba A, Cronin T, et al. COVID-19 pandemic preparation: using simulation for systems-based
learning to prepare the largest healthcare workforce an…
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psnet.ahrq.gov/node/43870/psn-pdf
January 28, 2015 - Peer review of medical practices: missed opportunities to
learn.
January 28, 2015
Kadar N. Peer review of medical practices: missed opportunities to learn. Am J Obstet Gynecol.
2014;211(6):596-601. doi:10.1016/j.ajog.2014.08.018.
https://psnet.ahrq.gov/issue/peer-review-medical-practices-missed-opportunities-learn…
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psnet.ahrq.gov/node/47279/psn-pdf
July 23, 2018 - No Place Like Home: Advancing the Safety of Care in the
Home.
July 23, 2018
Boston, MA: Institute for Healthcare Improvement; 2018.
https://psnet.ahrq.gov/issue/no-place-home-advancing-safety-care-home
The home care setting harbors unique challenges to patient safety. This report builds on a previous
evidence ass…
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psnet.ahrq.gov/node/60724/psn-pdf
July 29, 2020 - The safety of health care for ethnic minority patients: a
systematic review.
July 29, 2020
Chauhan A, Walton M, Manias E, et al. The safety of health care for ethnic minority patients: a systematic
review. Int J Equity Health. 2020;19(1):118. doi:10.1186/s12939-020-01223-2.
https://psnet.ahrq.gov/issue/safety-heal…
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psnet.ahrq.gov/node/33931/psn-pdf
June 23, 2015 - An analysis of major errors and equipment failures in
anesthesia management: considerations for prevention
and detection.
June 23, 2015
Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anesthesia
management: considerations for prevention and detection. Anesthesiology. 1984;60(…
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psnet.ahrq.gov/node/74130/psn-pdf
December 01, 2021 - Malpractice cases in breast surgery: an assessment of
litigation involving surgeons.
December 1, 2021
Fan B, Pardo J, Yu-Moe CW, et al. Malpractice cases in breast surgery: an assessment of litigation
involving surgeons. Ann Surg Oncol. 2021;28(13):8109-8115. doi:10.1245/s10434-021-10236-2.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/44653/psn-pdf
November 18, 2015 - Data quality associated with handwritten laboratory test
requests: classification and frequency of data-entry
errors for outpatient serology tests.
November 18, 2015
Vecellio E, Toouli G, Georgiou A, et al. Data quality associated with handwritten laboratory test requests:
classification and frequency of data-entr…
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psnet.ahrq.gov/node/47912/psn-pdf
April 24, 2019 - A systematic literature review and narrative synthesis on
the risks of medical discharge letters for patients' safety.
April 24, 2019
Schwarz CM, Hoffmann M, Schwarz P, et al. A systematic literature review and narrative synthesis on the
risks of medical discharge letters for patients' safety. BMC Health Serv Res. …
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psnet.ahrq.gov/node/866254/psn-pdf
July 10, 2024 - Top Penn State Health surgeon warned leaders about
transplant problems months before shutdown. Then he
was let go.
July 10, 2024
Massey W, Keith C. Spotlight PA: June 20, 2024.
https://psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems-
months-shutdown-then
Whistleblowers…
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psnet.ahrq.gov/node/37277/psn-pdf
July 28, 2010 - Drug selection errors in relation to medication labels: a
simulation study.
July 28, 2010
Garnerin P, Perneger T, Chopard P, et al. Drug selection errors in relation to medication labels: a
simulation study. Anaesthesia. 2007;62(11):1090-4.
https://psnet.ahrq.gov/issue/drug-selection-errors-relation-medication-lab…
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psnet.ahrq.gov/node/44409/psn-pdf
January 22, 2016 - "Anybody on this list that you're more worried about?"
Qualitative analysis exploring the functions of questions
during end of shift handoffs.
January 22, 2016
O'Brien CM, Flanagan ME, Bergman AA, et al. "Anybody on this list that you're more worried about?"
Qualitative analysis exploring the functions of question…
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psnet.ahrq.gov/node/44036/psn-pdf
April 15, 2015 - Can medical students identify a potentially serious
acetaminophen dosing error in a simulated encounter? A
case control study.
April 15, 2015
Dudas RA, Barone MA. Can medical students identify a potentially serious acetaminophen dosing error in a
simulated encounter? a case control study. BMC Med Educ. 2015;15(1).…
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psnet.ahrq.gov/node/43665/psn-pdf
November 20, 2015 - Patient safety education to change medical students'
attitudes and sense of responsibility.
November 20, 2015
Roh H, Park SJ, Kim T. Patient safety education to change medical students' attitudes and sense of
responsibility. Med Teach. 2015;37(10):908-14. doi:10.3109/0142159X.2014.970988.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/836825/psn-pdf
March 30, 2022 - Antibiotic prescribing errors in patients discharged from
the pediatric emergency department.
March 30, 2022
LaScala EC, Monroe AK, Hall GA, et al. Antibiotic prescribing errors in patients discharged from the
pediatric emergency department. Pediatr Emerg Care. 2022;38(1):e387-e392.
doi:10.1097/pec.000000000000229…
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psnet.ahrq.gov/node/47256/psn-pdf
October 03, 2018 - Does the perception of severity of medical error differ
between varying levels of clinical seniority?
October 3, 2018
Khan I, Arsanious M. Does the perception of severity of medical error differ between varying levels of
clinical seniority? Adv Med Educ Pract. 2018;9:443-452. doi:10.2147/AMEP.S146474.
https://psne…
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psnet.ahrq.gov/node/73250/psn-pdf
May 12, 2021 - Adverse events associated with home blood transfusion:
a retrospective cohort study.
May 12, 2021
Sharp R, Turner L, Altschwager J, et al. Adverse events associated with home blood transfusion: a
retrospective cohort study. J Clin Nurs. 2021;30(11-12):1751-1759. doi:10.1111/jocn.15734.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/35838/psn-pdf
March 28, 2011 - Unscheduled returns to the emergency department: an
outcome of medical errors?
March 28, 2011
Nuñez S, Hexdall A, Aguirre-Jaime A. Unscheduled returns to the emergency department: an outcome of
medical errors? Qual Saf Health Care. 2006;15(2):102-8.
https://psnet.ahrq.gov/issue/unscheduled-returns-emergency-depart…