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psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
September 01, 2015 - include keeping the patient's doors closed, posting notices reminding staff to lower their voices, reducing
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psnet.ahrq.gov/web-mm/allergy-holter
May 01, 2008 - Articles mentioning the role of the patient in reducing errors have tended to be opinion pieces.
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psnet.ahrq.gov/node/61079/psn-pdf
October 28, 2020 - Labeling of medicines and patient safety: evaluating methods of
reducing drug name confusion.?
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psnet.ahrq.gov/node/33631/psn-pdf
April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to
Promote a Culture of Safety
April 1, 2006
Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a
Culture of Safety. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…
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psnet.ahrq.gov/node/49656/psn-pdf
June 01, 2012 - Comanagement: Who's in Charge?
June 1, 2012
Cheng HQ. Comanagement: Who's in Charge? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/comanagement-whos-charge
The Case
A 77-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with a left
hip fracture to the orthopedic surg…
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psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary
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February 26, 2025
Innovation
Contact
…
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psnet.ahrq.gov/node/49866/psn-pdf
June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the
Operating Room
June 1, 2019
Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
The Case
A 43-year-old woman was admi…
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psnet.ahrq.gov/node/49387/psn-pdf
February 01, 2003 - Patient Mix-Up
February 1, 2003
Shojania KG. Patient Mix-Up. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/patient-mix
The Case
Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general
medical service at an academic medical center. Overnight, another man wit…
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psnet.ahrq.gov/node/33761/psn-pdf
February 01, 2014 - Interruptions and Distractions in Health Care: Improved
Safety With Mindfulness
February 1, 2014
Beyea SC. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness. PSNet
[internet]. 2014.
https://psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulne…
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psnet.ahrq.gov/node/46439/psn-pdf
August 20, 2018 - Hospital-readmission risk--isolating hospital effects from
patient effects.
August 20, 2018
Krumholz HM, Wang K, Lin Z, et al. Hospital-Readmission Risk - Isolating Hospital Effects from Patient
Effects. N Engl J Med. 2017;377(11):1055-1064. doi:10.1056/NEJMsa1702321.
https://psnet.ahrq.gov/issue/hospital-readmiss…
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psnet.ahrq.gov/node/44974/psn-pdf
April 12, 2019 - Medicare letters to curb overprescribing of controlled
substances had no detectable effect on providers.
April 12, 2019
Sacarny A, Yokum D, Finkelstein A, et al. Medicare Letters To Curb Overprescribing Of Controlled
Substances Had No Detectable Effect On Providers. Health Aff (Millwood). 2016;35(3):471-9.
doi:10.…
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psnet.ahrq.gov/node/46615/psn-pdf
January 23, 2019 - The surgical safety checklist and patient outcomes after
surgery: a prospective observational cohort study,
systematic review and meta-analysis.
January 23, 2019
Abbott TEF, Ahmad T, Phull MK, et al. The surgical safety checklist and patient outcomes after surgery: a
prospective observational cohort study, systema…
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psnet.ahrq.gov/node/43002/psn-pdf
March 12, 2014 - Exposure to media information about a disease can cause
doctors to misdiagnose similar-looking clinical cases.
March 12, 2014
Schmidt HG, Mamede S, Van den Berge K, et al. Exposure to media information about a disease can
cause doctors to misdiagnose similar-looking clinical cases. Acad Med. 2014;89(2):285-91.
doi…
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psnet.ahrq.gov/node/41176/psn-pdf
March 02, 2012 - Weekend hospitalization and additional risk of death: an
analysis of inpatient data.
March 2, 2012
Freemantle N, Richardson M, Wood J, et al. Weekend hospitalization and additional risk of death: An
analysis of inpatient data. J R Soc Med. 2012;105(2). doi:10.1258/jrsm.2012.120009.
https://psnet.ahrq.gov/issue/wee…
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psnet.ahrq.gov/node/44302/psn-pdf
August 04, 2015 - The Global Comparators project: international
comparison of 30-day in-hospital mortality by day of the
week.
August 4, 2015
Ruiz M, Bottle A, Aylin PP. The Global Comparators project: international comparison of 30-day in-hospital
mortality by day of the week. BMJ Qual Saf. 2015;24(8):492-504. doi:10.1136/bmjqs-20…
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psnet.ahrq.gov/node/37396/psn-pdf
March 28, 2012 - Risk-adjusted morbidity in teaching hospitals correlates
with reported levels of communication and collaboration
on surgical teams but not with scale measures of
teamwork climate, safety climate, or working conditions.
March 28, 2012
Davenport DL, Henderson WG, Mosca CL, et al. Risk-adjusted morbidity in teaching …
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psnet.ahrq.gov/node/37308/psn-pdf
January 05, 2012 - Effect of a rapid response system for patients in shock on
time to treatment and mortality during 5 years.
January 5, 2012
Sebat F, Musthafa AA, Johnson D, et al. Effect of a rapid response system for patients in shock on time to
treatment and mortality during 5 years. Crit Care Med. 2007;35(11):2568-75.
https://p…
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psnet.ahrq.gov/node/45608/psn-pdf
October 27, 2016 - Errors, omissions, and outliers in hourly vital signs
measurements in intensive care.
October 27, 2016
Maslove DM, Dubin JA, Shrivats A, et al. Errors, Omissions, and Outliers in Hourly Vital Signs
Measurements in Intensive Care. Crit Care Med. 2016;44(11):e1021-e1030.
https://psnet.ahrq.gov/issue/errors-omissions…
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psnet.ahrq.gov/node/41317/psn-pdf
January 31, 2013 - Variation in 17 obstetric care pathways: potential danger
for health professionals and patient safety?
January 31, 2013
Sarrechia M, Van Gerven E, Hermans L, et al. Variation in 17 obstetric care pathways: potential danger for
health professionals and patient safety? J Adv Nurs. 2013;69(2):278-85. doi:10.1111/j.136…
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psnet.ahrq.gov/node/37019/psn-pdf
September 15, 2011 - Just what the doctor ordered. Review of the evidence of
the impact of computerized physician order entry system
on medication errors.
September 15, 2011
Shamliyan TA, Duval S, Du J, et al. Just what the doctor ordered. Review of the evidence of the impact of
computerized physician order entry system on medication …