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psnet.ahrq.gov/node/45204/psn-pdf
September 18, 2016 - Alternative perspectives of safety in home delivered
health care: a sequential exploratory mixed method study.
September 18, 2016
Jones S. Alternative perspectives of safety in home delivered health care: a sequential exploratory mixed
method study. J Adv Nurs. 2016;72(10):2536-46. doi:10.1111/jan.13006.
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February 18, 2011 - The high cost of low-frequency events: the anatomy and
economics of surgical mishaps.
February 18, 2011
Couch NP, Tilney NL, Rayner AA, et al. The high cost of low-frequency events: the anatomy and
economics of surgical mishaps. N Engl J Med. 1981;304(11):634-7.
https://psnet.ahrq.gov/issue/high-cost-low-frequency…
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psnet.ahrq.gov/node/46945/psn-pdf
August 29, 2018 - Patient safety initiatives in obstetrics: a rapid review.
August 29, 2018
Antony J, Zarin W, Pham B', et al. Patient safety initiatives in obstetrics: a rapid review. BMJ Open.
2018;8(7):e020170. doi:10.1136/bmjopen-2017-020170.
https://psnet.ahrq.gov/issue/patient-safety-initiatives-obstetrics-rapid-review
Variou…
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psnet.ahrq.gov/node/849609/psn-pdf
May 31, 2023 - Impact of diagnostic checklists on the interpretation of
normal and abnormal electrocardiograms.
May 31, 2023
Staal J, Zegers R, Caljouw-Vos J, et al. Impact of diagnostic checklists on the interpretation of normal and
abnormal electrocardiograms. Diagnosis (Berl). 2022;10(2):121-129. doi:10.1515/dx-2022-0092.
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December 08, 2010 - Sentinel events. In memory of Ben—a case study.
December 8, 2010
Haas D. Sentinel events. In memory of Ben--a case study. Jt Comm Perspect. 1997;17(2):12-5.
https://psnet.ahrq.gov/issue/sentinel-events-memory-ben-case-study
Written from the perspective of a risk manager, the author tells the story of a medication a…
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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/50575/psn-pdf
October 23, 2019 - Dynamic pocket card for implementing ISBAR in shift
handover communication.
October 23, 2019
Schmidt T, Kocher DR, Mahendran P, et al. Dynamic Pocket Card for Implementing ISBAR in Shift
Handover Communication. Stud Health Technol Inform. 2019;267:224-229. doi:10.3233/SHTI190831.
https://psnet.ahrq.gov/issue/dynam…
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psnet.ahrq.gov/node/836759/psn-pdf
April 06, 2022 - Diversion is a Threat to Patient Safety: Adopting Best
Practices.
March 16, 2022
Institute for Safe Medication Practices. April 6, 2022.
https://psnet.ahrq.gov/issue/diversion-threat-patient-safety-adopting-best-practices
Drug diversion can result in patient harm due to reduced medication availability, impai…
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psnet.ahrq.gov/node/41577/psn-pdf
September 27, 2016 - Nursing perception of the impact of medication carts on
patient safety and ergonomics in a teaching health care
center.
September 27, 2016
Rochais E, Atkinson S, Bussières J-F. Nursing perception of the impact of medication carts on patient
safety and ergonomics in a teaching health care center. J Pharm Pract. 201…
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psnet.ahrq.gov/node/43733/psn-pdf
March 14, 2016 - The effect of an electronic checklist on critical care
provider workload, errors, and performance.
March 14, 2016
Thongprayoon C, Harrison AM, O'Horo JC, et al. The Effect of an Electronic Checklist on Critical Care
Provider Workload, Errors, and Performance. J Intensive Care Med. 2016;31(3):205-12.
doi:10.1177/08…
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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/46789/psn-pdf
March 20, 2018 - Healthcare professionals' views of smart glasses in
intensive care: a qualitative study.
March 20, 2018
Romare C, Hass U, Skär L. Healthcare professionals' views of smart glasses in intensive care: A qualitative
study. Intensive Crit Care Nurs. 2018;45:66-71. doi:10.1016/j.iccn.2017.11.006.
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psnet.ahrq.gov/node/41633/psn-pdf
January 01, 2013 - Determinants of success of quality improvement
collaboratives: what does the literature show?
December 31, 2012
Hulscher M, Schouten LMT, Grol R, et al. Determinants of success of quality improvement collaboratives:
what does the literature show? BMJ Qual Saf. 2013;22(1):19-31. doi:10.1136/bmjqs-2011-000651.
https…
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psnet.ahrq.gov/node/45658/psn-pdf
November 09, 2016 - Hospitals installed more sinks to stop infections. The
sinks can make the problem worse.
November 9, 2016
Branswell H. STAT. October 25, 2016.
https://psnet.ahrq.gov/issue/hospitals-installed-more-sinks-stop-infections-sinks-can-make-problem-worse
Hospitals have sought to improve hand hygiene with interventions su…
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psnet.ahrq.gov/node/866956/psn-pdf
October 16, 2024 - Obstetrics and gynecologic hospitalists and their focus:
impact on safety and quality metrics.
October 16, 2024
Gonzalez AK, Butler JR. Obstetrics and gynecologic hospitalists and their focus: impact on safety and
quality metrics. Obstet Gynecol Clin North Am. 2024;51(3):453-461. doi:10.1016/j.ogc.2024.05.001.
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December 16, 2017 - The business case for investing in physician well-being.
December 16, 2017
Shanafelt TD, Goh J, Sinsky CA. The Business Case for Investing in Physician Well-being. JAMA Intern
Med. 2017;177(12):1826-1832. doi:10.1001/jamainternmed.2017.4340.
https://psnet.ahrq.gov/issue/business-case-investing-physician-well-being
…
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psnet.ahrq.gov/node/45019/psn-pdf
April 27, 2016 - Effectiveness of surgical safety checklists in improving
patient safety.
April 27, 2016
Ragusa PS, Bitterman A, Auerbach B, et al. Effectiveness of Surgical Safety Checklists in Improving
Patient Safety. Orthopedics. 2016;39(2):e307-10. doi:10.3928/01477447-20160301-02.
https://psnet.ahrq.gov/issue/effectiveness-s…
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psnet.ahrq.gov/node/867016/psn-pdf
October 23, 2024 - An automated, dynamic radiation oncology prescription
checking system.
October 23, 2024
Pashtan IM, Kosak T, Shin K-Y, et al. An automated, dynamic radiation oncology prescription checking
system. Pract Radiat Oncol. 2024;14(4):343-352. doi:10.1016/j.prro.2023.12.002.
https://psnet.ahrq.gov/issue/automated-dynamic…
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psnet.ahrq.gov/node/44782/psn-pdf
January 13, 2016 - The Swiss cheese model of adverse event
occurrence—closing the holes.
January 13, 2016
Stein JE, Heiss K. The Swiss cheese model of adverse event occurrence--Closing the holes. Semin Pediatr
Surg. 2015;24(6):278-82. doi:10.1053/j.sempedsurg.2015.08.003.
https://psnet.ahrq.gov/issue/swiss-cheese-model-adverse-event…
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psnet.ahrq.gov/node/46221/psn-pdf
July 02, 2017 - Tools and methods for quality improvement and patient
safety in perinatal care.
July 2, 2017
Nathan AT, Kaplan HC. Tools and methods for quality improvement and patient safety in perinatal care.
Semin Perinatol. 2017;41(3):142-150. doi:10.1053/j.semperi.2017.03.002.
https://psnet.ahrq.gov/issue/tools-and-methods-q…