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psnet.ahrq.gov/node/837905/psn-pdf
August 24, 2022 - How cisgender clinicians can help prevent harm during
encounters with transgender patients.
August 24, 2022
doi:10.1001/amajethics.2022.753.
https://psnet.ahrq.gov/issue/how-cisgender-clinicians-can-help-prevent-harm-during-encounters-
transgender-patients
Implicit bias, discrimination, and stigmatization impact …
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psnet.ahrq.gov/node/73668/psn-pdf
September 01, 2021 - Leadership: an effective human factor during COVID-19.
September 1, 2021
Dhahri AA, Refson J. Leadership: an effective human factor during COVID-19. BMJ Leader. 2021;5:203-
205. doi:10.1136/leader-2020-000384.
https://psnet.ahrq.gov/issue/leadership-effective-human-factor-during-covid-19
Hierarchy and professional…
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psnet.ahrq.gov/node/837024/psn-pdf
May 04, 2022 - The potential for leveraging machine learning to filter
medication alerts.
May 4, 2022
Liu S, Kawamoto K, Del Fiol G, et al. The potential for leveraging machine learning to filter medication
alerts. J Am Med Inform Assoc. 2022;29(5):891-899. doi:10.1093/jamia/ocab292.
https://psnet.ahrq.gov/issue/potential-levera…
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psnet.ahrq.gov/node/43677/psn-pdf
November 19, 2014 - Reporting and Learning Systems for Medication Errors:
The Role of Pharmacovigilance Centres.
November 19, 2014
Bencheikh SR, Cousins D, Benabdallah G, et al. Geneva, Switzerland: World Health Organization; October
2014. ISBN: 9789241507943.
https://psnet.ahrq.gov/issue/reporting-and-learning-systems-medication-err…
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psnet.ahrq.gov/node/43758/psn-pdf
March 17, 2015 - A patient safety checklist for the cardiac catheterisation
laboratory.
March 17, 2015
Cahill TJ, Clarke SC, Simpson IA, et al. A patient safety checklist for the cardiac catheterisation laboratory.
Heart. 2015;101(2):91-3. doi:10.1136/heartjnl-2014-306927.
https://psnet.ahrq.gov/issue/patient-safety-checklist-card…
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psnet.ahrq.gov/node/34100/psn-pdf
February 09, 2011 - Safety of patients isolated for infection control.
February 9, 2011
Stelfox HT, Bates DW, Redelmeier DA. Safety of patients isolated for infection control. JAMA.
2003;290(14):1899-1905.
https://psnet.ahrq.gov/issue/safety-patients-isolated-infection-control
This study discovered that patients isolated for coloniza…
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psnet.ahrq.gov/node/73396/psn-pdf
June 16, 2021 - The impact of the built environment on patient falls in
hospital rooms: an integrative review.
June 16, 2021
Pati D, Valipoor S, Lorusso L, et al. The impact of the built environment on patient falls in hospital rooms:
an integrative review. J Patient Saf. 2021;17(4):273-281. doi:10.1097/pts.0000000000000613.
http…
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psnet.ahrq.gov/node/60801/psn-pdf
August 12, 2020 - Targeting zero harm: a stretch goal that risks breaking the
spring.
August 12, 2020
Meddings J, Saint S, Lilford RJ, et al. Targeting zero harm: a stretch goal that risks breaking the spring.
NEJM Catal Innov Care Deliv. 2020;1(4). doi:10.1056/cat.20.0354.
https://psnet.ahrq.gov/issue/targeting-zero-harm-stretch-g…
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psnet.ahrq.gov/node/42643/psn-pdf
October 09, 2013 - FDA requiring color changes to Duragesic (fentanyl) pain
patches to aid safety?emphasizing that accidental
exposure to used patches can cause death.
October 9, 2013
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 23, 2013.
https://psnet.ahrq.gov/issue/fda-requiring-color-change…
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psnet.ahrq.gov/node/34721/psn-pdf
November 19, 2015 - Preventing medical injury.
November 19, 2015
Leape LL, Lawthers AG, Brennan TA, et al. Preventing medical injury. QRB - Qual Rev Bull.
1993;19(5):144-149. doi:10.1016/s0097-5990(16)30608-x.
https://psnet.ahrq.gov/issue/preventing-medical-injury
Reviewing cases of medical error in the Harvard Medical Practice Study…
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psnet.ahrq.gov/node/43786/psn-pdf
December 17, 2014 - Aviation tools to improve patient safety.
December 17, 2014
Ross J. Aviation tools to improve patient safety. J Perianesth Nurs. 2014;29(6):508-10.
doi:10.1016/j.jopan.2014.09.004.
https://psnet.ahrq.gov/issue/aviation-tools-improve-patient-safety
The aviation industry offers insights and tools applicable to error…
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psnet.ahrq.gov/node/74118/psn-pdf
January 01, 2022 - From HRO to HERO: making health equity a core system
capability.
November 24, 2021
Moy E, Hausmann LRM, Clancy CM. From HRO to HERO: making health equity a core system capability.
Am J Med Qual. 2022;37(1):81-83. doi:10.1097/jmq.0000000000000020.
https://psnet.ahrq.gov/issue/hro-hero-making-health-equity-core-syst…
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psnet.ahrq.gov/node/72591/psn-pdf
December 23, 2020 - Bias and racism teaching rounds at an academic medical
center.
December 23, 2020
Capers Q, Bond DA, Nori US. Bias and racism teaching rounds at an academic medical center. Chest.
2020;158(6):2688-2694. doi:10.1016/j.chest.2020.08.2073.
https://psnet.ahrq.gov/issue/bias-and-racism-teaching-rounds-academic-medical-c…
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psnet.ahrq.gov/node/45987/psn-pdf
April 26, 2017 - Using simulation to prepare nursing staff for the move to
a new building.
April 26, 2017
Knippa S, Senecal P-A. Using Simulation to Prepare Nursing Staff for the Move to a New Building. J
Nurses Prof Dev. 2017;33(2):E1-E5. doi:10.1097/NND.0000000000000329.
https://psnet.ahrq.gov/issue/using-simulation-prepare-nurs…
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psnet.ahrq.gov/node/45611/psn-pdf
May 27, 2025 - Funding Announcement for Projects Targeting the
Reduction of Healthcare-Associated Infections.
July 7, 2021
Rockville, MD: Agency for Healthcare Research and Quality; July 7 2021.
https://psnet.ahrq.gov/issue/funding-announcement-projects-targeting-reduction-healthcare-associated-
infections
Health care–associate…
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psnet.ahrq.gov/node/44843/psn-pdf
September 06, 2016 - Addressing the Global Shortages of Medicines, and the
Safety and Accessibility of Children's Medication.
September 6, 2016
Geneva, Switzerland: World Health Organization; 2015.
https://psnet.ahrq.gov/issue/addressing-global-shortages-medicines-and-safety-and-accessibility-childrens-
medication
Drug shortages have…
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psnet.ahrq.gov/node/72687/psn-pdf
January 27, 2021 - Learning from errors with the new COVID-19 vaccines.
January 27, 2021
ISMP Medication Safety Alert! Acute Care Edition. January 14, 2021;26(1);1-5.
https://psnet.ahrq.gov/issue/learning-errors-new-covid-19-vaccines
Learning from error rests on transparency efforts buttressed by frontline reports. This a…
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psnet.ahrq.gov/node/33927/psn-pdf
June 23, 2015 - Errors, incidents and accidents in anaesthetic practice.
June 23, 2015
Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study. Errors, incidents and
accidents in anaesthetic practice. Anaesth Intensive Care. 1993;21(5):506-19.
https://psnet.ahrq.gov/issue/errors-incidents-and-accidents-anae…
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psnet.ahrq.gov/node/73489/psn-pdf
July 15, 2021 - A diagnostic time-out to improve differential diagnosis in
pediatric abdominal pain.
July 15, 2021
Kasick RT, Melvin JE, Perera ST, et al. A diagnostic time-out to improve differential diagnosis in pediatric
abdominal pain. Diagnosis (Berl). 2021;8(2):209-217. doi:10.1515/dx-2019-0054.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/73249/psn-pdf
May 12, 2021 - I-PASS handover system: a decade of evidence demands
action.
May 12, 2021
Shahian DM. I-PASS handover system: a decade of evidence demands action. BMJ Qual Saf.
2021;30(10):769-774. doi:10.1136/bmjqs-2021-013314.
https://psnet.ahrq.gov/issue/i-pass-handover-system-decade-evidence-demands-action
The I-PASS structu…