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psnet.ahrq.gov/node/43036/psn-pdf
March 27, 2014 - Redesigning hospital alarms for patient safety: alarmed
and potentially dangerous.
March 27, 2014
Chopra V, McMahon LF. Redesigning hospital alarms for patient safety: alarmed and potentially
dangerous. JAMA. 2014;311(12):1199-200. doi:10.1001/jama.2014.710.
https://psnet.ahrq.gov/issue/redesigning-hospital-alarms…
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psnet.ahrq.gov/node/60569/psn-pdf
June 10, 2020 - Workplace team resilience: a systematic review and
conceptual development.
June 10, 2020
Hartwig A, Clarke S, Johnson S, et al. Workplace team resilience: s systematic review and conceptual
development. Org Psychol Rev. 2020;10(3-4):169-200. doi:10.1177/2041386620919476.
https://psnet.ahrq.gov/issue/workplace-team…
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psnet.ahrq.gov/node/40043/psn-pdf
March 03, 2011 - Effect of a "Lean" intervention to improve safety
processes and outcomes on a surgical emergency unit.
March 3, 2011
McCulloch P, Kreckler S, New S, et al. Effect of a "Lean" intervention to improve safety processes and
outcomes on a surgical emergency unit. BMJ. 2010;341:c5469. doi:10.1136/bmj.c5469.
https://psne…
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psnet.ahrq.gov/node/50577/psn-pdf
October 23, 2019 - Medicare's Oversight of Ambulatory Surgery Centers
Report.
October 23, 2019
Washington, DC: Office of the Inspector General; September 2019. Report No. OEI-01-15-00400.
https://psnet.ahrq.gov/issue/medicares-oversight-ambulatory-surgery-centers-report
Ambulatory surgery centers (ASC) play an increasing role in com…
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psnet.ahrq.gov/node/38705/psn-pdf
June 17, 2009 - Ambulance stretcher adverse events.
June 17, 2009
Wang HE, Weaver MD, Abo BN, et al. Ambulance stretcher adverse events. Qual Saf Health Care.
2009;18(3):213-216. doi:10.1136/qshc.2007.024562.
https://psnet.ahrq.gov/issue/ambulance-stretcher-adverse-events
This study analyzed more than 670 reported adverse events …
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psnet.ahrq.gov/node/46800/psn-pdf
May 16, 2018 - Ireland investigates cervical cancer screening scandal.
May 16, 2018
O'Loughlin E. New York Times. April 30, 2018.
https://psnet.ahrq.gov/issue/ireland-investigates-cervical-cancer-screening-scandal
Large-scale adverse events should lead to system examination and improvement. This newspaper article
reports on misr…
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psnet.ahrq.gov/node/43912/psn-pdf
February 25, 2015 - Patient Safety in Dialysis Access.
February 25, 2015
Widmer MK, Malik J, eds. Contrib Nephrol. 2015;184:1-270. ISBN: 9783318027051.
https://psnet.ahrq.gov/issue/patient-safety-dialysis-access
Patients with chronic kidney failure are at high risk for adverse events from treatment errors. This
publication raises awa…
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psnet.ahrq.gov/node/44673/psn-pdf
April 15, 2016 - The safety of emergency medicine.
April 15, 2016
Ramlakhan S, Qayyum H, Burke D, et al. The safety of emergency medicine. Emerg Med J.
2016;33(4):293-9. doi:10.1136/emermed-2014-204564.
https://psnet.ahrq.gov/issue/safety-emergency-medicine
Emergency medicine is considered a high-risk environment, but little resea…
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psnet.ahrq.gov/node/60024/psn-pdf
March 11, 2020 - Artificial intelligence and surgical decision-making.
March 11, 2020
Loftus TJ, Tighe PJ, Filiberto AC, et al. Artificial intelligence and surgical decision-making. JAMA Surg.
2019;155(2):148-158. doi:10.1001/jamasurg.2019.4917.
https://psnet.ahrq.gov/issue/artificial-intelligence-and-surgical-decision-making
Arti…
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psnet.ahrq.gov/node/44091/psn-pdf
January 04, 2019 - Isolation precautions for visitors.
January 4, 2019
Munoz-Price LS, Banach DB, Bearman G, et al. Isolation Precautions for Visitors. Infect Control Hosp
Epidemiol. 2015;36(7):747-758. doi:10.1017/ice.2015.67.
https://psnet.ahrq.gov/issue/isolation-precautions-visitors
This expert guidance provides recommendations …
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psnet.ahrq.gov/node/837074/psn-pdf
May 11, 2022 - The Color of Care.
May 11, 2022
Chicago, IL: Harpo Productions, Smithsonian Channel: May 2022.
https://psnet.ahrq.gov/issue/color-care
The COVID-19 pandemic revealed the impact of racial disparities and inequities on patient safety for
patients of color. This film shares stories of families whose care was unsafe. …
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psnet.ahrq.gov/node/73669/psn-pdf
September 01, 2021 - Infection Prevention Compendium For Long-Term Care
Facilities.
September 1, 2021
Center for Healthy Aging--New York Academy of Medicine, Yale School of Nursing.
https://psnet.ahrq.gov/issue/infection-prevention-compendium-long-term-care-facilities
Healthcare-associated infections (HAIs) challenge safety in long-te…
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psnet.ahrq.gov/node/47533/psn-pdf
June 19, 2019 - Patient Safety: A Health Affairs Briefing.
June 19, 2019
Project Hope.
https://psnet.ahrq.gov/issue/patient-safety-health-affairs-briefing
To Err Is Human was released almost 2 decades ago and continues to influence a growing area of study
aimed at improving health care and reducing medical error. This in-person a…
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psnet.ahrq.gov/node/43100/psn-pdf
April 02, 2014 - Taking National Action to Prevent and Eliminate
Healthcare-Associated Infections.
April 2, 2014
Kahn KL, Battles JB, eds. Med Care. 2014;52:i-ii,s1-s100.
https://psnet.ahrq.gov/issue/taking-national-action-prevent-and-eliminate-healthcare-associated-infections
This special issue explores a national initiativ…
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psnet.ahrq.gov/node/37938/psn-pdf
July 23, 2008 - An integrative review of the current evidence on the
relationship between hand hygiene interventions and the
incidence of health care-associated infections.
July 23, 2008
Backman C, Zoutman DE, Marck PB. An integrative review of the current evidence on the relationship
between hand hygiene interventions and the in…
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psnet.ahrq.gov/node/867645/psn-pdf
July 01, 2022 - A call to action for anticoagulation stewardship.
July 1, 2022
Burnett AE, Barnes GD. A call to action for anticoagulation stewardship. Res Pract Thromb Haemost.
2022;6(5):e12757. doi:10.1002/rth2.12757.
https://psnet.ahrq.gov/issue/call-action-anticoagulation-stewardship
Anticoagulants are high-risk medications d…
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psnet.ahrq.gov/node/46718/psn-pdf
August 08, 2018 - Workplace Violence Prevention: Implementing Strategies
for Safer Healthcare Organizations.
August 8, 2018
Joint Commission.
https://psnet.ahrq.gov/issue/workplace-violence-prevention-implementing-strategies-safer-healthcare-
organizations
Workplace violence in health care can affect the safety of both staff and p…
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psnet.ahrq.gov/node/39299/psn-pdf
September 27, 2016 - Development and evaluation of an observational tool for
assessing surgical flow disruptions and their impact on
surgical performance.
September 27, 2016
Parker SEH, Laviana AA, Wadhera RK, et al. Development and evaluation of an observational tool for
assessing surgical flow disruptions and their impact on surgica…
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psnet.ahrq.gov/node/34788/psn-pdf
March 28, 2005 - Cost of medication-related problems at a university
hospital.
March 28, 2005
Schneider PJ; Gift MG; Lee YP; Rothermich EA; Sill BE
https://psnet.ahrq.gov/issue/cost-medication-related-problems-university-hospital
This study used retrospective chart review to determine estimated costs of defined medication-related
…
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psnet.ahrq.gov/node/35193/psn-pdf
July 10, 2008 - Diagnostic error in internal medicine.
July 10, 2008
Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med.
2005;165(13):1493-1499.
https://psnet.ahrq.gov/issue/diagnostic-error-internal-medicine
This study identified 100 cases of diagnostic error in internal medicine and conducte…