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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/35332/psn-pdf
September 21, 2005 - Are language barriers associated with serious medical
events in hospitalized pediatric patients?
September 21, 2005
Cohen AL. Are Language Barriers Associated With Serious Medical Events in Hospitalized Pediatric
Patients? Pediatrics. 2005;116(3):575-579. doi:10.1542/peds.2005-0521.
https://psnet.ahrq.gov/issue/ar…
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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/47549/psn-pdf
March 04, 2019 - Interventions against bullying of prelicensure students
and nursing professionals: an integrative review.
March 4, 2019
Rutherford DE, Gillespie GL, Smith CR. Interventions against bullying of prelicensure students and nursing
professionals: An integrative review. Nurs Forum. 2019;54(1):84-90. doi:10.1111/nuf.12301…
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psnet.ahrq.gov/node/73878/psn-pdf
September 29, 2021 - Interventions to improve communication at hospital
discharge and rates of readmission: a systematic review
and meta-analysis.
September 29, 2021
Becker C, Zumbrunn S, Beck K, et al. Interventions to improve communication at hospital discharge and
rates of readmission. JAMA Netw Open. 2021;4(8):e2119346. doi:10.100…
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psnet.ahrq.gov/node/866311/psn-pdf
January 01, 2025 - Systematic review of types of safety incidents and the
processes and systems used for safety incident reporting
in care homes.
July 17, 2024
Scott J, Sykes K, Waring J, et al. Systematic review of types of safety incidents and the processes and
systems used for safety incident reporting in care homes. J Adv Nurs. …
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psnet.ahrq.gov/node/35762/psn-pdf
January 02, 2017 - Using Failure Mode and Effects Analysis for safe
administration of chemotherapy to hospitalized children
with cancer.
January 2, 2017
Robinson DL, Heigham M, Clark J. Using Failure Mode and Effects Analysis for safe administration of
chemotherapy to hospitalized children with cancer. Jt Comm J Qual Patient Saf. 20…
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psnet.ahrq.gov/node/838641/psn-pdf
October 19, 2022 - Optimizing Pediatric Patient Safety in the Emergency Care
Setting.
October 19, 2022
Joseph MM, Mahajan P, Snow SK, et al. Optimizing Pediatric Patient Safety in the Emergency Care
Setting. Pediatrics. 2022;150(5):e2022059673. doi:10.1542/peds.2022-059673.
https://psnet.ahrq.gov/issue/optimizing-pediatric-patient-s…
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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/35207/psn-pdf
December 19, 2009 - Patient safety concerns arising from test results that
return after hospital discharge.
December 19, 2009
Roy CL, Poon EG, Karson A, et al. Patient safety concerns arising from test results that return after hospital
discharge. Ann Intern Med. 2005;143(2):121-128.
https://psnet.ahrq.gov/issue/patient-safety-concer…
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psnet.ahrq.gov/node/39277/psn-pdf
August 22, 2018 - Preventing maternal death.
August 22, 2018
Preventing maternal death. Sentinel Event Alert. 2010;44(44):1-4.
https://psnet.ahrq.gov/issue/preventing-maternal-death
The Joint Commission issues Sentinel Event Alerts to highlight areas of high risk and to promote the rapid
adoption of risk reduction strategies. Adher…
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psnet.ahrq.gov/node/48180/psn-pdf
August 21, 2019 - Burnout and Resilience and Quality and Safety Programs
in Obstetrics and Gynecology.
August 21, 2019
Main EK, Fowler JM, Gabbe SG, eds. Clin Obstet Gynecol. 2019;62:vii-xii,403-626.
https://psnet.ahrq.gov/issue/burnout-and-resilience-and-quality-and-safety-programs-obstetrics-and-
gynecology
Obstetrics is a high-…
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psnet.ahrq.gov/node/854389/psn-pdf
October 11, 2023 - Alliance for Innovation on Maternal Health: Consensus
Bundle on Sepsis in Obstetric Care.
October 11, 2023
Bauer ME, Albright C, Prabhu M, et al. Alliance for Innovation on Maternal Health: Consensus Bundle on
Sepsis in Obstetric Care. Obstet Gynecol. 2023;142(3):481-492. doi:10.1097/aog.0000000000005304.
https://…
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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/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/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/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/44957/psn-pdf
March 09, 2016 - Government and industry fail to protect the public when
they suggest "carefully following instructions" is enough
to prevent vaccine errors.
March 9, 2016
ISMP Medication Safety Alert! Acute care edition. February 25, 2016;21(4):1-5.
https://psnet.ahrq.gov/issue/government-and-industry-fail-protect-public-when-the…
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psnet.ahrq.gov/node/60196/psn-pdf
April 01, 2020 - Mask shortage straps pharmacists who need them to
keep medicines pure.
April 1, 2020
Jewett C, Lupkin S. Health Shots. National Public Radio. March 20, 2020.
https://psnet.ahrq.gov/issue/mask-shortage-straps-pharmacists-who-need-them-keep-medicines-pure
Disruptions in medication compounding activities can impact s…
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psnet.ahrq.gov/node/44935/psn-pdf
April 15, 2016 - Pharmacy-led medication reconciliation programmes at
hospital transitions: a systematic review and meta-
analysis.
April 15, 2016
Mekonnen AB, McLachlan AJ, Brien J-AE. Pharmacy-led medication reconciliation programmes at hospital
transitions: a systematic review and meta-analysis. J Clin Pharm Ther. 2016;41(2):12…