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psnet.ahrq.gov/node/44869/psn-pdf
November 18, 2016 - Fake and expired medications in simulation-based
education: an underappreciated risk to patient safety.
November 18, 2016
Torrie J, Cumin D, Sheridan J, et al. Fake and expired medications in simulation-based education: an
underappreciated risk to patient safety. BMJ Qual Saf. 2016;25(12):917-920. doi:10.1136/bmjqs…
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psnet.ahrq.gov/node/47619/psn-pdf
April 08, 2019 - A decade of health information technology usability
challenges and the path forward.
April 8, 2019
Ratwani RM, Reider J, Singh H. A Decade of Health Information Technology Usability Challenges and the
Path Forward. JAMA. 2019;321(8):743-744. doi:10.1001/jama.2019.0161.
https://psnet.ahrq.gov/issue/decade-health-in…
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psnet.ahrq.gov/node/47574/psn-pdf
November 21, 2018 - The architecture of safety: an emerging priority for
improving patient safety.
November 21, 2018
Joseph A, Henriksen K, Malone E. The Architecture Of Safety: An Emerging Priority For Improving Patient
Safety. Health Aff (Millwood). 2018;37(11):1884-1891. doi:10.1377/hlthaff.2018.0643.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/44067/psn-pdf
June 02, 2015 - Surgical team member assessment of the safety of
surgery practice in 38 South Carolina hospitals.
June 2, 2015
Singer SJ, Jiang W, Huang LC, et al. Surgical team member assessment of the safety of surgery practice
in 38 South Carolina hospitals. Med Care Res Rev. 2015;72(3):298-323. doi:10.1177/1077558715577479.
h…
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psnet.ahrq.gov/node/46314/psn-pdf
November 01, 2020 - AHRQ Safety Program for Improving Antibiotic Use.
July 9, 2019
Agency for Healthcare Research and Quality, Johns Hopkins Medicine Armstrong Institute for Patient
Safety and Quality, and University of Chicago.
https://psnet.ahrq.gov/issue/ahrq-safety-program-improving-antibiotic-use
Improving antibiotic use is a st…
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psnet.ahrq.gov/node/72672/psn-pdf
January 27, 2021 - Use of simulation to measure the effects of just-in-time
information to prevent nursing medication errors: a
randomized controlled study.
January 27, 2021
Berg TA, Hebert SH, Chyka D, et al. Use of Simulation to Measure the Effects of Just-in-Time Information
to Prevent Nursing Medication Errors. Simul Healthc. 20…
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psnet.ahrq.gov/node/45571/psn-pdf
January 18, 2017 - How communication among members of the health care
team affects maternal morbidity and mortality.
January 18, 2017
Brennan RA, Keohane CA. How Communication Among Members of the Health Care Team Affects
Maternal Morbidity and Mortality. J Obstet Gynecol Neonatal Nurs. 2016;45(6):878-884.
doi:10.1016/j.jogn.2016.03…
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psnet.ahrq.gov/node/43039/psn-pdf
August 24, 2016 - How Doctors Think.
August 24, 2016
Groopman J. Boston, MA: Houghton Mifflin; 2007. ISBN: 0618610030.
https://psnet.ahrq.gov/issue/how-doctors-think
In this book, the author presents several stories that illustrate the forces that shape physician decision-
making and may lead to diagnostic mistakes. Borrowing from …
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psnet.ahrq.gov/node/47664/psn-pdf
April 03, 2019 - Minor flow disruptions, traffic-related factors and their
effect on major flow disruptions in the operating room.
April 3, 2019
Joseph A, Khoshkenar A, Taaffe KM, et al. Minor flow disruptions, traffic-related factors and their effect on
major flow disruptions in the operating room. BMJ Qual Saf. 2019;28(4):276-283…
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psnet.ahrq.gov/node/855001/psn-pdf
November 01, 2023 - Rethinking Patient Safety: A Discussion Guide for
Patients, Healthcare Providers and Leaders.
November 1, 2023
Gilbert R, Asselbergs M, Davis D, et al. Healthcare Excellence Canada; 2023.
https://psnet.ahrq.gov/issue/rethinking-patient-safety-discussion-guide-patients-healthcare-providers-and-
leaders
Patient saf…
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psnet.ahrq.gov/node/44490/psn-pdf
September 16, 2015 - Implementation of a custom alert to prevent medication-
timing errors associated with computerized prescriber
order entry.
September 16, 2015
Idemoto LM, Williams BL, Ching JM, et al. Implementation of a custom alert to prevent medication-timing
errors associated with computerized prescriber order entry. Am J Heal…
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psnet.ahrq.gov/node/837152/psn-pdf
May 18, 2022 - AHRQ Safety Program for Intensive Care Units:
Preventing CLABSI and CAUTI: Final Report.
May 18, 2022
Molefe A, Hung L, Hayes K, et al. Rockville MD: Agency for healthcare Research and Quality; 2022. AHRQ
Publication No. 17(22)-0019.
https://psnet.ahrq.gov/issue/ahrq-safety-program-intensive-care-units-preventing-…
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psnet.ahrq.gov/node/45745/psn-pdf
August 02, 2017 - Emergency diagnosis of cancer and previous general
practice consultations: insights from linked patient
survey data.
August 2, 2017
Abel GA, Mendonca SC, McPhail S, et al. Emergency diagnosis of cancer and previous general practice
consultations: insights from linked patient survey data. Br J Gen Pract. 2017;67(65…
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psnet.ahrq.gov/node/48034/psn-pdf
May 22, 2019 - Chasing zero harm in radiation oncology: using pre-
treatment peer review.
May 22, 2019
Vijayakumar S, Duggar WN, Packianathan S, et al. Chasing Zero Harm in Radiation Oncology: Using Pre-
treatment Peer Review. Front Oncol. 2019;9:302. doi:10.3389/fonc.2019.00302.
https://psnet.ahrq.gov/issue/chasing-zero-harm-ra…
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psnet.ahrq.gov/node/854255/psn-pdf
October 04, 2023 - Empowering telemetry technicians and enhancing
communication to improve in-hospital cardiac arrest
survival.
October 4, 2023
McCoy C, Keshvani N, Warsi M, et al. Empowering telemetry technicians and enhancing communication to
improve in-hospital cardiac arrest survival. BMJ Open Qual. 2023;12(3):e002220. doi:10.11…
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psnet.ahrq.gov/node/854826/psn-pdf
October 25, 2023 - Observing sources of system resilience using in situ
alarm simulations.
October 25, 2023
McLoone M, McNamara M, Jennings MA, et al. Observing sources of system resilience using in situ alarm
simulations. J Hosp Med. 2023;18(11):994-998. doi:10.1002/jhm.13217.
https://psnet.ahrq.gov/issue/observing-sources-system-r…
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psnet.ahrq.gov/node/46129/psn-pdf
September 28, 2017 - Missed diagnosis of cardiovascular disease in outpatient
general medicine: insights from malpractice claims data.
September 28, 2017
Quinn GR, Ranum D, Song E, et al. Missed Diagnosis of Cardiovascular Disease in Outpatient General
Medicine: Insights from Malpractice Claims Data. Jt Comm J Qual Patient Saf. 2017;43…
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psnet.ahrq.gov/node/47713/psn-pdf
June 14, 2019 - Medication appropriateness in vulnerable older adults:
healthy skepticism of appropriate polypharmacy.
June 14, 2019
Fried TR, Mecca MC. Medication Appropriateness in Vulnerable Older Adults: Healthy Skepticism of
Appropriate Polypharmacy. J Am Geriatr Soc. 2019;67(6):1123-1127. doi:10.1111/jgs.15798.
https://psne…
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psnet.ahrq.gov/node/72832/psn-pdf
March 10, 2021 - Communication and Transparency as a Means to
Strengthening Workplace Culture During COVID-19.
March 10, 2021
Nadkarni A, Levy-Carrick NC, Kroll DS, et al. Communication And Transparency As A Means To
Strengthening Workplace Culture During Covid-19. National Academy of Medicine; 2021.
doi:10.31478/202103a.
https:/…
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psnet.ahrq.gov/node/60213/psn-pdf
April 08, 2020 - FDA alerts patients and health care professionals of
EpiPen auto-injector errors related to device malfunctions
and user administration.
April 8, 2020
FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device
malfunctions and user administration. MedWatch Safety Alert. Silv…