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psnet.ahrq.gov/issue/adverse-event-protocol-interventional-pain-medicine-importance-organized-response
January 12, 2022 - Study
Adverse event protocol for interventional pain medicine: the importance of an organized response.
Citation Text:
Sitzman BT. Adverse Event Protocol for Interventional Pain Medicine: The Importance of an Organized Response. Pain Medicine. 2008;9(suppl 1). doi:10.1111/j.1526-4637.2…
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psnet.ahrq.gov/issue/assessing-performance-surgical-teams
July 05, 2017 - Study
Assessing the performance of surgical teams.
Citation Text:
Leach LS, Myrtle RC, Weaver FA, et al. Assessing the performance of surgical teams. Health Care Manage Rev. 2009;34(1):29-41. doi:10.1097/01.HMR.0000342977.84307.64.
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psnet.ahrq.gov/issue/system-weaknesses-contributing-causes-accidents-health-care
August 31, 2022 - Study
System weaknesses as contributing causes of accidents in health care.
Citation Text:
Ternov S, Akselsson R. System weaknesses as contributing causes of accidents in health care. Int J Qual Health Care. 2005;17(1):5-13.
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psnet.ahrq.gov/issue/cost-poor-blood-specimen-quality-and-errors-preanalytical-processes
April 22, 2009 - Review
The cost of poor blood specimen quality and errors in preanalytical processes.
Citation Text:
Green SF. The cost of poor blood specimen quality and errors in preanalytical processes. Clin Biochem. 2013;46(13-14):1175-9. doi:10.1016/j.clinbiochem.2013.06.001.
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psnet.ahrq.gov/issue/impact-care-quality-commission-provider-performance-room-improvement
November 18, 2015 - Book/Report
Impact of the Care Quality Commission on Provider Performance: Room for Improvement?
Citation Text:
Impact of the Care Quality Commission on Provider Performance: Room for Improvement? Smithson R, Richardson E, Roberts J, et al. The King's Fund, Alliance Manchester Business S…
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psnet.ahrq.gov/issue/reducing-preventable-medication-safety-events-recognizing-renal-risk
June 27, 2011 - Study
Reducing preventable medication safety events by recognizing renal risk.
Citation Text:
Fields W, Tedeschi C, Foltz J, et al. Reducing preventable medication safety events by recognizing renal risk. Clin Nurse Spec. 2008;22(2):73-8; quiz 79-80. doi:10.1097/01.NUR.0000311795.69476…
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psnet.ahrq.gov/issue/cost-nurse-sensitive-adverse-events
June 16, 2021 - Study
The cost of nurse-sensitive adverse events.
Citation Text:
Pappas SH. The cost of nurse-sensitive adverse events. J Nurs Adm. 2008;38(5):230-236. doi:10.1097/01.NNA.0000312770.19481.ce.
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psnet.ahrq.gov/issue/intralipid-medication-errors-neonatal-intensive-care-unit
January 02, 2017 - Study
Intralipid medication errors in the neonatal intensive care unit.
Citation Text:
Chuo J, Lambert G, Hicks RW. Intralipid medication errors in the neonatal intensive care unit. Jt Comm J Qual Patient Saf. 2007;33(2):104-11.
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psnet.ahrq.gov/issue/role-chief-executive-officers-quality-improvement-qualitative-study
September 17, 2014 - Study
The role of chief executive officers in a quality improvement: a qualitative study.
Citation Text:
Parand A, Dopson S, Vincent CA. The role of chief executive officers in a quality improvement : a qualitative study. BMJ Open. 2013;3(1). doi:10.1136/bmjopen-2012-001731.
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psnet.ahrq.gov/issue/simulation-based-clinical-rehearsals-method-improving-patient-safety
September 28, 2022 - Commentary
Simulation-based clinical rehearsals as a method for improving patient safety.
Citation Text:
Arnold J, Cashin M, Olutoye OO. Simulation-Based Clinical Rehearsals as a Method for Improving Patient Safety. JAMA Surg. 2018;153(12):1143-1144. doi:10.1001/jamasurg.2018.3526.
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psnet.ahrq.gov/issue/patient-safety-helping-medical-students-understand-error-healthcare
December 16, 2009 - Study
Patient safety: helping medical students understand error in healthcare.
Citation Text:
Patey R, Flin R, Cuthbertson BH, et al. Patient safety: helping medical students understand error in healthcare. Qual Saf Health Care. 2007;16(4):256-9.
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psnet.ahrq.gov/issue/disclosure-harmful-medical-error-patients-review-recommendations-pathologists
September 21, 2022 - Review
Disclosure of harmful medical error to patients: a review with recommendations for pathologists.
Citation Text:
Heher YK, Dintzis SM. Disclosure of Harmful Medical Error to Patients: A Review With Recommendations for Pathologists. Adv Anat Pathol. 2018;25(2):124-130. doi:10.1097/P…
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psnet.ahrq.gov/issue/ades-and-automation
January 15, 2014 - Commentary
ADEs and automation.
Citation Text:
Kloppenborg E, Wheeler A, Luria J. ADEs and automation. Nurs Manage. 2009;40(1):43-7. doi:10.1097/01.NUMA.0000343983.46376.31.
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psnet.ahrq.gov/issue/teams-psychologists-helping-teams-evolution-science-team-training
February 26, 2020 - Commentary
Emerging Classic
Teams of psychologists helping teams: the evolution of the science of team training.
Citation Text:
Bisbey TM, Reyes DL, Traylor AM, et al. Teams of psychologists helping teams: The evolution of the science of team training. Am Psycho…
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psnet.ahrq.gov/issue/analysis-laboratory-critical-value-reporting-large-academic-medical-center
December 05, 2013 - Study
Analysis of laboratory critical value reporting at a large academic medical center.
Citation Text:
Dighe AS, Rao A, Coakley AB, et al. Analysis of laboratory critical value reporting at a large academic medical center. Am J Clin Pathol. 2006;125(5):758-64.
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psnet.ahrq.gov/issue/impact-nurse-peer-review-culture-safety
November 29, 2023 - Commentary
Impact of nurse peer review on a culture of safety.
Citation Text:
Herrington CR, Hand MW. Impact of Nurse Peer Review on a Culture of Safety. J Nurs Care Qual. 2019;34(2):158-162. doi:10.1097/NCQ.0000000000000361.
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psnet.ahrq.gov/issue/themed-issue-innovations-medication-safety
August 30, 2017 - Special or Theme Issue
Themed Issue on Innovations in Medication Safety.
Citation Text:
Kane-Gill SL. Innovations in Medication Safety: Services and Technologies to Enhance the Understanding and Prevention of Adverse Drug Reactions. Pharmacotherapy. 2018;38(8):782-784. doi:10.1002/phar.2…
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psnet.ahrq.gov/issue/ethics-oversight-and-quality-improvement-initiatives
August 04, 2021 - Study
Ethics, oversight and quality improvement initiatives.
Citation Text:
Taylor HA, Pronovost PJ, Sugarman J. Ethics, oversight and quality improvement initiatives. Quality and Safety in Health Care. 2010;19(4). doi:10.1136/qshc.2009.038034.
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psnet.ahrq.gov/issue/hospital-checklists-are-meant-save-lives-so-why-do-they-often-fail
July 31, 2013 - Newspaper/Magazine Article
Hospital checklists are meant to save lives—so why do they often fail?
Citation Text:
Anthes E. Hospital checklists are meant to save lives - so why do they often fail? Nature. 2015;523(7562):516-8. doi:10.1038/523516a.
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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