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psnet.ahrq.gov/node/849133/psn-pdf
May 17, 2023 - The association between patient safety culture and
adverse events - a scoping review.
May 17, 2023
Vikan M, Haugen AS, Bjørnnes AK, et al. The association between patient safety culture and adverse
events – a scoping review. BMC Health Serv Res. 2023;23(1):300. doi:10.1186/s12913-023-09332-8.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/43465/psn-pdf
February 18, 2015 - Hospital Readmissions Reduction Program: implications
for pharmacy.
February 18, 2015
Boesen KAG, Leal S, Sheehan VC, et al. Hospital Readmissions Reduction Program: implications for
pharmacy. Am J Health Syst Pharm. 2015;72(3):237-44. doi:10.2146/ajhp140177.
https://psnet.ahrq.gov/issue/hospital-readmissions-redu…
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psnet.ahrq.gov/node/73476/psn-pdf
July 07, 2021 - The role of apology laws in medical malpractice.
July 7, 2021
Ross NE, Newman WJ. J Am Acad Psychiatry Law. 2021;49(3):406-414.
https://psnet.ahrq.gov/issue/role-apology-laws-medical-malpractice
Open disclosure of errors and adverse events is increasingly encouraged in healthcare, but clinicians
frequently ci…
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psnet.ahrq.gov/node/849336/psn-pdf
May 24, 2023 - AI may be on its way to your doctor’s office, but it’s not
ready to see patients.
May 24, 2023
Tahir D. KFF Health News. May 12, 2023.
https://psnet.ahrq.gov/issue/ai-may-be-its-way-your-doctors-office-its-not-ready-see-patients
Real-time use of artificial intelligence (AI) in health care settings continues to cau…
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psnet.ahrq.gov/node/851204/psn-pdf
July 05, 2023 - Drugmakers are abandoning cheap generics, and now US
cancer patients can’t get meds.
July 5, 2023
Allen A. KFF Health News. June 21, 2023.
https://psnet.ahrq.gov/issue/drugmakers-are-abandoning-cheap-generics-and-now-us-cancer-patients-
cant-get-meds
A variety of supply-chain, quality control, and economic factor…
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psnet.ahrq.gov/node/44940/psn-pdf
September 20, 2016 - Dual-process cognitive interventions to enhance
diagnostic reasoning: a systematic review.
September 20, 2016
Lambe KA, O'Reilly G, Kelly BD, et al. Dual-process cognitive interventions to enhance diagnostic
reasoning: a systematic review. BMJ Qual Saf. 2016;25(10):808-820. doi:10.1136/bmjqs-2015-004417.
https://p…
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psnet.ahrq.gov/node/43811/psn-pdf
July 18, 2018 - 2014 Annual Benchmarking Report: Malpractice Risks in
the Diagnostic Process.
July 18, 2018
Hoffman J, ed. Cambridge, MA: CRICO Strategies; 2014.
https://psnet.ahrq.gov/issue/2014-annual-benchmarking-report-malpractice-risks-diagnostic-process
This analysis of more than 4700 diagnosis-related malpractice claims fo…
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psnet.ahrq.gov/node/41653/psn-pdf
December 30, 2014 - Impact of a hospital-wide hand hygiene initiative on
healthcare-associated infections: results of an interrupted
time series.
December 30, 2014
Kirkland KB, Homa KA, Lasky RA, et al. Impact of a hospital-wide hand hygiene initiative on healthcare-
associated infections: results of an interrupted time series. BMJ Q…
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psnet.ahrq.gov/node/47459/psn-pdf
October 10, 2018 - People, processes, health IT and accurate patient
identification.
October 10, 2018
Quick Safety. October 1, 2018;(45):1-2.
https://psnet.ahrq.gov/issue/people-processes-health-it-and-accurate-patient-identification
This newsletter article reviews common problems related to patient identification and recommends
st…
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psnet.ahrq.gov/node/43749/psn-pdf
December 10, 2014 - Alarm management: first things first: using reliable data
to eliminate unnecessary alarms.
December 10, 2014
Vanderveen T. Patient Saf Qual Healthc. November/December 2014;11:38-40,42-45.
https://psnet.ahrq.gov/issue/alarm-management-first-things-first-using-reliable-data-eliminate-unnecessary-
alarms
Spotlightin…
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psnet.ahrq.gov/node/73077/psn-pdf
March 24, 2021 - Well-Being Playbook 2.0. A COVID-19 Resource for
Hospital and Health System Leaders.
March 24, 2021
AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.
https://psnet.ahrq.gov/issue/well-being-playbook-20-covid-19-resource-hospital-and-health-system-leaders
Human factors enginee…
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psnet.ahrq.gov/node/46020/psn-pdf
July 21, 2017 - Towards high-reliability organising in healthcare: a
strategy for building organisational capacity.
July 21, 2017
Aboumatar HJ, Weaver SJ, Rees D, et al. Towards high-reliability organising in healthcare: a strategy for
building organisational capacity. BMJ Qual Saf. 2017;26(8):663-670. doi:10.1136/bmjqs-2016-00624…
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psnet.ahrq.gov/node/42539/psn-pdf
September 27, 2016 - Causes of medication administration errors in hospitals: a
systematic review of quantitative and qualitative
evidence.
September 27, 2016
Keers RN, Williams SD, Cooke J, et al. Causes of medication administration errors in hospitals: a
systematic review of quantitative and qualitative evidence. Drug Saf. 2013;36(1…
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psnet.ahrq.gov/node/43565/psn-pdf
March 22, 2016 - The role of failure mode and effects analysis in health
care.
March 22, 2016
Fibuch E, Ahmed A. The role of failure mode and effects analysis in health care. Physician Exec.
2014;40(4):28-32.
https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care
Failure mode and effects analysis (FMEA) h…
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psnet.ahrq.gov/node/852748/psn-pdf
August 23, 2023 - Compliance with central line maintenance bundle and
infection rates.
August 23, 2023
Tripathi S, McGarvey J, Lee K, et al. Compliance with central line maintenance bundle and infection rates.
Pediatrics. 2023;152(3):e2022059688. doi:10.1542/peds.2022-059688.
https://psnet.ahrq.gov/issue/compliance-central-line-mai…
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psnet.ahrq.gov/node/44378/psn-pdf
August 05, 2015 - Advancing medication safety: establishing a National
Action Plan for Adverse Drug Event Prevention.
August 5, 2015
Harris Y, Hu DJ, Lee C, et al. Advancing Medication Safety: Establishing a National Action Plan for
Adverse Drug Event Prevention. Jt Comm J Qual Patient Saf. 2015;41(8):351-60.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/837040/psn-pdf
May 04, 2022 - Use duodenoscopes with innovative designs to enhance
safety: FDA Safety Communication.
May 4, 2022
Silver Spring, MD: US Food and Drug Administration; April 5, 2022.
https://psnet.ahrq.gov/issue/use-duodenoscopes-innovative-designs-enhance-safety-fda-safety-
communication
The challenge of medical device steriliza…
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psnet.ahrq.gov/node/40598/psn-pdf
August 10, 2011 - An inpatient fall prevention initiative in a tertiary care
hospital.
August 10, 2011
Weinberg J, Proske D, Szerszen A, et al. An inpatient fall prevention initiative in a tertiary care hospital. Jt
Comm J Qual Patient Saf. 2011;37(7):317-325.
https://psnet.ahrq.gov/issue/inpatient-fall-prevention-initiative-tertia…
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psnet.ahrq.gov/node/45782/psn-pdf
January 18, 2017 - Standardization of inpatient handoff communication.
January 18, 2017
Jewell JA. Standardization of Inpatient Handoff Communication. Pediatrics. 2016;138(5):e20162681.
doi:10.1542/peds.2016-2681.
https://psnet.ahrq.gov/issue/standardization-inpatient-handoff-communication
Handoffs at shift changes are vulnerable to…
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psnet.ahrq.gov/node/39731/psn-pdf
August 04, 2010 - Comparing errors in ED computer-assisted vs
conventional pediatric drug dosing and administration.
August 4, 2010
Yamamoto LG, Kanemori J. Comparing errors in ED computer-assisted vs conventional pediatric drug
dosing and administration. Am J Emerg Med. 2010;28(5):588-92. doi:10.1016/j.ajem.2009.02.009.
https://ps…