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psnet.ahrq.gov/node/60263/psn-pdf
April 22, 2020 - Rationing protective gear means checking on coronavirus
patients less often. This can be deadly.
April 22, 2020
Kaplan J, Presser L, Miller M. ProPublica. April 10, 2020.
https://psnet.ahrq.gov/issue/rationing-protective-gear-means-checking-coronavirus-patients-less-often-can-
be-deadly
Increased complexity and p…
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psnet.ahrq.gov/node/35502/psn-pdf
May 27, 2011 - Medication errors: a prospective cohort study of hand-
written and computerised physician order entry in the
intensive care unit.
May 27, 2011
Shulman R, Singer M, Goldstone J, et al. Medication errors: a prospective cohort study of hand-written and
computerised physician order entry in the intensive care unit. Cr…
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psnet.ahrq.gov/node/43321/psn-pdf
August 02, 2015 - Costs associated with surgical site infections in Veterans
Affairs hospitals.
August 2, 2015
Schweizer ML, Cullen JJ, Perencevich E, et al. Costs Associated With Surgical Site Infections in Veterans
Affairs Hospitals. JAMA Surg. 2014;149(6):575-81. doi:10.1001/jamasurg.2013.4663.
https://psnet.ahrq.gov/issue/costs…
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psnet.ahrq.gov/node/35019/psn-pdf
June 22, 2009 - Improving patient safety in critical care: big challenge,
exciting opportunity/L'amelioration de la securite des
patients a l'unite des soins intensifs : un grand defi, une
occasion stimulante.
June 22, 2009
Dodek P. Improving patient safety in critical care: big challenge, exciting opportunity. Can J Anaesth.
20…
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psnet.ahrq.gov/node/44838/psn-pdf
February 10, 2016 - ADVERSE drug events: incidence and risk reduction
across the care continuum.
February 10, 2016
Wanderer JP, Rathmell JP. ADVERSE Drug Events: Incidence & risk reduction across the care continuum.
Anesthesiology. 2016;124(1):A23. doi:10.1097/01.anes.0000473722.20007.03.
https://psnet.ahrq.gov/issue/adverse-drug-eve…
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psnet.ahrq.gov/node/45986/psn-pdf
March 29, 2017 - Pediatric prehospital medication dosing errors: a national
survey of paramedics.
March 29, 2017
Hoyle JD, Crowe RP, Bentley MA, et al. Pediatric prehospital medication dosing errors: a national survey of
paramedics. Prehosp Emerg Care. 2017;21(2):185-191. doi:10.1080/10903127.2016.1227001.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/34870/psn-pdf
April 18, 2016 - Unintended medication discrepancies at the time of
hospital admission.
April 18, 2016
Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital
admission. Arch Intern Med. 2005;165(4):424-9.
https://psnet.ahrq.gov/issue/unintended-medication-discrepancies-time-hospita…
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psnet.ahrq.gov/node/44048/psn-pdf
November 20, 2015 - Clinical handover of the critically ill postoperative patient:
an integrative review.
November 20, 2015
Gardiner TM, Marshall AP, Gillespie BM. Clinical handover of the critically ill postoperative patient: an
integrative review. Aust Crit Care. 2015;28(4):226-34. doi:10.1016/j.aucc.2015.02.001.
https://psnet.ahrq…
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psnet.ahrq.gov/node/50425/psn-pdf
September 04, 2019 - Why doctors still offer treatments that may not help.
September 4, 2019
Frakt A. New York Times. August 26, 2019.
https://psnet.ahrq.gov/issue/why-doctors-still-offer-treatments-may-not-help
The slow adoption of improvement innovations is a persistent challenge to high-quality and safe patient
care. This newspaper…
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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/854252/psn-pdf
October 04, 2023 - Standardization and visualization of the surgical time-out.
October 4, 2023
Levy BE, Wilt WS, Lantz S, et al. Standardization and visualization of the surgical time-out. J Patient Saf.
2023;19(7):453-459. doi:10.1097/pts.0000000000001156.
https://psnet.ahrq.gov/issue/standardization-and-visualization-surgical-time-…
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psnet.ahrq.gov/node/46336/psn-pdf
August 23, 2017 - Improving the Working Environment for Safe Surgical
Care.
August 23, 2017
Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Royal College of Surgeons of
Edinburgh; July 31, 2017.
https://psnet.ahrq.gov/issue/improving-working-environment-safe-surgical-care
Surgical training is demanding and can r…
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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…
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psnet.ahrq.gov/node/47462/psn-pdf
October 31, 2018 - Emergency department checklist: an innovation to
improve safety in emergency care.
October 31, 2018
Redfern E, Hoskins R, Gray J, et al. Emergency department checklist: an innovation to improve safety in
emergency care. BMJ Open Qual. 2018;7(3):e000325. doi:10.1136/bmjoq-2018-000325.
https://psnet.ahrq.gov/issue/e…
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psnet.ahrq.gov/node/836833/psn-pdf
March 30, 2022 - As a nurse faces prison for a deadly error, her colleagues
worry: could I be next?
March 30, 2022
Kelman B. Kaiser Health News. March 22, 2022
https://psnet.ahrq.gov/issue/nurse-faces-prison-deadly-error-her-colleagues-worry-could-i-be-next
Criminalization of medical mistakes typifies the blame-focused approach pa…
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psnet.ahrq.gov/node/864383/psn-pdf
March 13, 2024 - Cyberattack on UnitedHealth still impacting prescription
access: "These are threats to life".
March 13, 2024
Sganga N, Triay A. CBS Evening News. February 29, 2024.
https://psnet.ahrq.gov/issue/cyberattack-unitedhealth-still-impacting-prescription-access-these-are-threats-
life
As health care becomes more technol…
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psnet.ahrq.gov/node/44473/psn-pdf
September 27, 2016 - Medication errors in hospitals: a literature review of
disruptions to nursing practice during medication
administration.
September 27, 2016
Hayes C, Jackson D, Davidson PM, et al. Medication errors in hospitals: a literature review of disruptions to
nursing practice during medication administration. J Clin Nurs. 2…
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psnet.ahrq.gov/node/35176/psn-pdf
June 23, 2009 - Mapping changes in surgical mortality over 9 years by
peer review audit.
June 23, 2009
Thompson A, Ashraf Z, Burton H, et al. Mapping changes in surgical mortality over 9 years by peer review
audit. Br J Surg. 2005;92(11):1449-52.
https://psnet.ahrq.gov/issue/mapping-changes-surgical-mortality-over-9-years-peer-re…
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psnet.ahrq.gov/node/60800/psn-pdf
January 01, 2021 - Changing hospital organisational culture for improved
patient outcomes: developing and implementing the
Leadership Saves Lives intervention.
August 12, 2020
Linnander EL, McNatt Z, Boehmer K, et al. Changing hospital organisational culture for improved patient
outcomes: developing and implementing the leadership s…
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psnet.ahrq.gov/node/74064/psn-pdf
May 27, 2021 - Achieving zero inequity: lessons learned from patient
safety.
May 27, 2021
Gandhi TK. NEJM Catalyst. May 27, 2021.
https://psnet.ahrq.gov/issue/achieving-zero-inequity-lessons-learned-patient-safety
The COVID-19 pandemic has shown a spotlight on bias, disparities, and inequity in the healthcare system.
The author…