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psnet.ahrq.gov/node/44697/psn-pdf
June 21, 2016 - Saving Lives and Saving Money: Hospital-Acquired
Conditions Update.
June 21, 2016
Rockville, MD: Agency for Healthcare Research and Quality; December 2015. AHRQ Publication No. 16-
0009-EF.
https://psnet.ahrq.gov/issue/saving-lives-and-saving-money-hospital-acquired-conditions-update
The Partnership for Patients …
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psnet.ahrq.gov/node/33657/psn-pdf
September 01, 2007 - Rediscovering the Power of the Surgical M&M
Conference: The M+M Matrix
September 1, 2007
Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
Perspective
There is a slumbe…
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psnet.ahrq.gov/node/33586/psn-pdf
December 15, 2024 - Alert Fatigue
December 15, 2024
Alert Fatigue. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/alert-fatigue
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Bac…
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psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
April 27, 2022 - Readmissions and Adverse Events After Discharge
Citation Text:
Readmissions and Adverse Events After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3…
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psnet.ahrq.gov/node/33570/psn-pdf
June 15, 2024 - Diagnostic Errors
June 15, 2024
Diagnostic Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/diagnostic-errors
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 20…
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psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
December 23, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication
Citation Text:
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/865374/psn-pdf
March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and
Challenges
March 27, 2024
Tighe P, Mossburg S, Gale B. Artificial Intelligence and Patient Safety: Promise and Challenges. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
Introducti…
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psnet.ahrq.gov/issue/family-safety-reporting-hospitalized-children-medical-complexity
September 18, 2024 - Study
Family safety reporting in hospitalized children with medical complexity.
Citation Text:
Mercer AN, Mauskar S, Baird JD, et al. Family safety reporting in hospitalized children with medical complexity. Pediatrics. 2022;150(2):e2021055098. doi:10.1542/peds.2021-055098.
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psnet.ahrq.gov/issue/risk-management-or-just-different-risk-national-survey-newborn-units-following-patient-safety
April 12, 2011 - Study
Risk management, or just a different risk: a national survey of newborn units following a patient safety alert.
Citation Text:
Freer Y. Risk management, or just a different risk? Archives of Disease in Childhood - Fetal and Neonatal Edition. 2006;91(5). doi:10.1136/adc.2005.08954…
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psnet.ahrq.gov/issue/computerized-decision-support-medication-dosing-renal-insufficiency-randomized-controlled
September 30, 2009 - Study
Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial.
Citation Text:
Terrell KM, Perkins AJ, Hui SL, et al. Computerized decision support for medication dosing in renal insufficiency: a randomized, controlled trial. Ann Emerg …
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psnet.ahrq.gov/issue/approaches-reducing-most-important-patient-errors-primary-health-care-patient-and
April 12, 2011 - Study
Approaches to reducing the most important patient errors in primary health-care: patient and professional perspectives.
Citation Text:
Buetow S, Kiata L, Liew T, et al. Approaches to reducing the most important patient errors in primary health-care: patient and professional persp…
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psnet.ahrq.gov/issue/review-literature-examining-linkages-between-organizational-factors-medical-errors-and
June 24, 2010 - Review
A review of the literature examining linkages between organizational factors, medical errors, and patient safety.
Citation Text:
Hoff T, Jameson L, Hannan E, et al. A review of the literature examining linkages between organizational factors, medical errors, and patient safety. …
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psnet.ahrq.gov/issue/decreased-bile-duct-injury-rate-during-laparoscopic-cholecystectomy-era-80-hour-resident
March 17, 2021 - Study
Decreased bile duct injury rate during laparoscopic cholecystectomy in the era of the 80-hour resident workweek.
Citation Text:
Yaghoubian A, Saltmarsh G, Rosing DK, et al. Decreased bile duct injury rate during laparoscopic cholecystectomy in the era of the 80-hour resident work…
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psnet.ahrq.gov/issue/building-safety-net
December 21, 2009 - Newspaper/Magazine Article
Building a safety net.
Citation Text:
Rogoski RR. Building a safety net. By leveraging huge amounts of data and applying it to a wide array of projects and purposes, hospitals stay focused on patient safety and make headway. Health management technology. 2006…
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psnet.ahrq.gov/issue/reducing-emergency-department-charting-and-ordering-errors-room-number-watermark-electronic
November 22, 2017 - Study
Reducing emergency department charting and ordering errors with a room number watermark on the electronic medical record display.
Citation Text:
Yamamoto LG. Reducing emergency department charting and ordering errors with a room number watermark on the electronic medical record dis…
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psnet.ahrq.gov/issue/near-misses-are-opportunity-improve-patient-safety-adapting-strategies-high-reliability
July 01, 2011 - Review
Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability organizations to healthcare.
Citation Text:
Van Spall H, Kassam A, Tollefson TT. Near-misses are an opportunity to improve patient safety: adapting strategies of high reliability orga…
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psnet.ahrq.gov/issue/developing-and-pilot-testing-practical-measures-preanalytic-surgical-specimen-identification
June 16, 2011 - Study
Developing and pilot testing practical measures of preanalytic surgical specimen identification defects.
Citation Text:
Bixenstine PJ, Zarbo RJ, Holzmueller CG, et al. Developing and pilot testing practical measures of preanalytic surgical specimen identification defects. Am J M…
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psnet.ahrq.gov/issue/extended-work-shifts-and-neurobehavioral-performance-resident-physicians
July 15, 2020 - Study
Emerging Classic
Extended work shifts and neurobehavioral performance in resident-physicians.
Citation Text:
Rahman SA, Sullivan JP, Barger LK, et al. Extended Work Shifts and Neurobehavioral Performance in Resident-Physicians. Pediatrics. 2021;147(3):e202…
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psnet.ahrq.gov/issue/risk-factors-retained-surgical-items-meta-analysis-and-proposed-risk-stratification-system
January 18, 2013 - Study
Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system.
Citation Text:
Moffatt-Bruce SD, Cook CH, Steinberg SM, et al. Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. J Surg Res. 2014;190(…
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psnet.ahrq.gov/issue/assessment-use-patient-vital-sign-data-preventing-misidentification-and-medical-errors
February 16, 2022 - Commentary
Assessment of the use of patient vital sign data for preventing misidentification and medical errors.
Citation Text:
Maul J, Straub J. Assessment of the use of patient vital sign data for preventing misidentification and medical errors. Healthcare (Basel). 2022;10(12):2440. do…