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psnet.ahrq.gov/issue/organizational-silence-and-hidden-threats-patient-safety
September 27, 2010 - Commentary
Organizational silence and hidden threats to patient safety.
Citation Text:
Henriksen K, Dayton E. Organizational Silence and Hidden Threats to Patient Safety. Health Serv Res. 2006;41(4p2). doi:10.1111/j.1475-6773.2006.00564.x.
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psnet.ahrq.gov/issue/patient-safety-and-diagnostic-error-tips-your-next-shift
January 15, 2009 - Commentary
Patient safety and diagnostic error: tips for your next shift.
Citation Text:
Sinclair D, Croskerry P. Patient safety and diagnostic error: tips for your next shift. Can Fam Physician. 2010;56(1):28-30.
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psnet.ahrq.gov/issue/your-companys-secret-change-agents
June 09, 2021 - Commentary
Your company's secret change agents.
Citation Text:
Pascale RT, Sternin J. Your company's secret change agents. Harv Bus Rev. 2005;83(5):72-81, 153.
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psnet.ahrq.gov/issue/improving-care-transitions-optimizing-medication-reconciliation
June 17, 2014 - Commentary
Improving care transitions: optimizing medication reconciliation.
Citation Text:
Association AP, Pharmacists AS of H-S, Steeb D, et al. Improving care transitions: optimizing medication reconciliation. J Am Pharm Assoc (2003). 2012;52(4):e43-e52. doi:10.1331/JAPhA.2012.12527…
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psnet.ahrq.gov/issue/do-you-hear-what-i-hear-communication-practices-about-medications-between-physicians-and
August 02, 2016 - Study
Do you hear what I hear? Communication practices about medications between physicians and clients with chronic illness in Canada.
Citation Text:
Do you hear what I hear? Communication practices about medications between physicians and clients with chronic illness in Canada. Sears…
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psnet.ahrq.gov/issue/sleep-science-and-policy-change
September 21, 2022 - Commentary
Sleep, science, and policy change.
Citation Text:
Wylie D. Sleep, science, and policy change. N Engl J Med. 2005;352(2):196-7.
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psnet.ahrq.gov/issue/interdisciplinary-communication-uncharted-source-medical-error
September 24, 2016 - Review
Interdisciplinary communication: an uncharted source of medical error?
Citation Text:
Alvarez G, Coiera E. Interdisciplinary communication: an uncharted source of medical error? J Crit Care. 2006;21(3):236-42; discussion 242.
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psnet.ahrq.gov/issue/sample-sample-carryover-source-analytical-laboratory-error-and-its-relevance-integrated
January 12, 2022 - Study
Sample to sample carryover: a source of analytical laboratory error and its relevance to integrated clinical chemistry/immunoassay systems.
Citation Text:
Armbruster DA, Alexander DB. Sample to sample carryover: a source of analytical laboratory error and its relevance to integra…
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psnet.ahrq.gov/issue/revitalizing-established-rapid-response-team
September 23, 2020 - Commentary
Revitalizing an established rapid response team.
Citation Text:
Genardi ME, Cronin SN, Thomas LD. Revitalizing an established rapid response team. Dimens Crit Care Nurs. 2008;27(3):104-9. doi:10.1097/01.DCC.0000286837.95720.8c.
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psnet.ahrq.gov/issue/disclosing-adverse-events-you-said-it-now-write-it
July 14, 2010 - Commentary
Disclosing adverse events: you said it, now write it.
Citation Text:
Monson MS. Disclosing adverse events: you said it, now write it. Nurs Manage. 2006;37(8):16-7, 55.
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psnet.ahrq.gov/issue/medical-devices-and-patient-safety
February 22, 2012 - Commentary
Medical devices and patient safety.
Citation Text:
Mattox E. Medical devices and patient safety. Crit Care Nurse. 2012;32(4):60-8. doi:10.4037/ccn2012925.
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psnet.ahrq.gov/node/42771/psn-pdf
January 08, 2014 - Patient Safety Collaboration.
January 8, 2014
National Quality Forum; NQF.
https://psnet.ahrq.gov/issue/patient-safety-collaboration
This program aligns with the Partnership for Patients to engage patients, reduce readmissions, and
improve safety in maternity care by convening experts and developing best practices…
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psnet.ahrq.gov/node/36606/psn-pdf
January 31, 2007 - Cause of death: sloppy doctors.
January 31, 2007
Caplan J. Time. January 15, 2007.
https://psnet.ahrq.gov/issue/cause-death-sloppy-doctors
This article reports on an industry-supported initiative to reduce medication errors by encouraging
physicians to use electronic prescribing through a free Web-based tool.
htt…
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psnet.ahrq.gov/node/42243/psn-pdf
May 01, 2013 - Safer Sign Out.
May 1, 2013
Emergency Medicine Patient Safety Foundation.
https://psnet.ahrq.gov/issue/safer-sign-out
This Web site offers information about a standardized process for handoffs in emergency care designed to
help reduce risks and improve reliability.
https://psnet.ahrq.gov/issue/safer-sign-out
http…
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psnet.ahrq.gov/web-mm/monitoring-fetal-health
September 08, 2010 - expansion of an individual patient's tracing, that can only be accomplished by obscuring, degrading, or reducing
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psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
January 01, 2024 - • Proper planning and execution of the CABG operation has been shown to
prolong life by reducing
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psnet.ahrq.gov/node/846563/psn-pdf
March 21, 2023 - support for healthcare workers involved in adverse events by
ensuring that resources are available for reducing
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - of older persons in their own pharmaceutical care has the potential to be particularly beneficial in reducing
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - medication errors, such as those resulting from illegible handwriting, but they are not as effective at reducing
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psnet.ahrq.gov/node/38918/psn-pdf
September 02, 2009 - Hospitals own up to errors.
September 2, 2009
Landro L. Wall Street Journal. August 25, 2009:D1.
https://psnet.ahrq.gov/issue/hospitals-own-errors
This column shares the experience of hospitals and families whose involvement in open disclosure has
resulted in improved care, reduced litigation costs, and patient pa…