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psnet.ahrq.gov/issue/exploring-care-left-undone-pediatric-nursing
October 25, 2017 - Study
Exploring care left undone in pediatric nursing.
Citation Text:
Bagnasco A, Rossi S, Dasso N, et al. Exploring care left undone in pediatric nursing. J Patient Saf. 2022;18(6):e903-e911. doi:10.1097/pts.0000000000001044.
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psnet.ahrq.gov/issue/common-general-surgical-never-events-analysis-nhs-england-never-event-data
April 14, 2021 - Study
Common general surgical never events: analysis of NHS England never event data.
Citation Text:
Omar I, Singhal R, Wilson M, et al. Common general surgical never events: analysis of NHS England never event data. Int J Qual Health Care. 2021;33(1):mzab045. doi:10.1093/intqhc/mzab045.…
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psnet.ahrq.gov/issue/perfect-storm-exam-medical-error-and-factors-contributing-its-possible-escalation
October 20, 2021 - Commentary
The perfect storm: exam of a medical error and factors contributing to its possible escalation.
Citation Text:
Walters GK. The perfect storm: exam of a medical error and factors contributing to its possible escalation. J Patient Saf. 2021;17(4):e264-e267. doi:10.1097/pts.00000…
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psnet.ahrq.gov/issue/performance-variability-perioperative-sentinel-events-report-nationwide-data-set
November 04, 2020 - Study
Performance variability in perioperative sentinel events: report on a nationwide data set.
Citation Text:
Reijmerink IM, Bos K, Leistikow IP, et al. Performance variability in perioperative sentinel events: report on a nationwide data set. Br J Surg. 2022;109(7):573-575. doi:10.109…
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psnet.ahrq.gov/issue/algorithm-based-smartphone-apps-assess-risk-skin-cancer-adults-systematic-review-diagnostic
July 29, 2020 - Review
Classic
Algorithm based smartphone apps to assess risk of skin cancer in adults: systematic review of diagnostic accuracy studies.
Citation Text:
Freeman K, Dinnes J, Chuchu N, et al. Algorithm based smartphone apps to assess risk of skin cancer in adults…
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psnet.ahrq.gov/issue/root-cause-analyses-reported-adverse-events-occurring-during-gastrointestinal-scope-and-tube
November 17, 2021 - Study
Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association.
Citation Text:
Soncrant C, Mills PD, Neily J, et al. Root cause analyses of reported adverse events occurring during gastrointest…
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psnet.ahrq.gov/issue/interventions-increase-patient-safety-long-term-care-facilities-umbrella-review
September 01, 2021 - Review
Interventions to increase patient safety in long-term care facilities-umbrella review.
Citation Text:
Świtalski J, Wnuk K, Tatara T, et al. Interventions to increase patient safety in long-term care facilities-umbrella review. Int J Environ Res Public Health. 2022;19(22):15354. do…
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psnet.ahrq.gov/issue/remote-patient-monitoring-during-covid-19-unexpected-patient-safety-benefit
July 20, 2022 - Commentary
Remote patient monitoring during COVID-19: an unexpected patient safety benefit.
Citation Text:
Pronovost PJ, Cole MD, Hughes RM. Remote patient monitoring during COVID-19: an unexpected patient safety benefit. JAMA. 2022;327(12):1125-1126. doi:10.1001/jama.2022.2040.
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psnet.ahrq.gov/issue/sustaining-and-spreading-reduction-adverse-drug-events-multicenter-collaborative
November 16, 2022 - Study
Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.
Citation Text:
Tham E, Calmes HM, Poppy A, et al. Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative. Pediatrics. 2011;128(2):e438-45. doi:10.1542…
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psnet.ahrq.gov/issue/organisational-culture-variation-across-hospitals-and-connection-patient-safety-climate
March 17, 2010 - Study
Organisational culture: variation across hospitals and connection to patient safety climate.
Citation Text:
Speroff T, Nwosu S, Greevy R, et al. Organisational culture: variation across hospitals and connection to patient safety climate. Qual Saf Health Care. 2010;19(6):592-6. do…
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psnet.ahrq.gov/issue/how-safe-are-paediatric-emergency-departments-national-prospective-cohort-study
May 20, 2020 - Study
How safe are paediatric emergency departments? A national prospective cohort study.
Citation Text:
Plint AC, Newton AS, Stang A, et al. How safe are paediatric emergency departments? A national prospective cohort study. BMJ Qual Saf. 2022;31(11):806-817. doi:10.1136/bmjqs-2021-0146…
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psnet.ahrq.gov/issue/partnership-pathway-diagnostic-excellence-challenges-and-successes-implementing-safer-dx
April 13, 2022 - Study
Partnership as a pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning Lab.
Citation Text:
Sloane J, Singh H, Upadhyay DK, et al. Partnership as a pathway to diagnostic excellence: the challenges and successes of implementing the Safer…
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psnet.ahrq.gov/issue/triggers-contributing-health-care-clinicians-disruptive-behaviors
June 24, 2020 - Study
Triggers contributing to health care clinicians' disruptive behaviors.
Citation Text:
Bae S-H, Dang D, Karlowicz KA, et al. Triggers contributing to health care clinicians' disruptive behaviors. J Patient Saf. 2020;16(3):e148-e155. doi:10.1097/pts.0000000000000288.
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psnet.ahrq.gov/issue/register-based-research-adverse-events-revealing-incomplete-records-threatening-patient
October 06, 2021 - Review
Register-based research of adverse events revealing incomplete records threatening patient safety.
Citation Text:
Kinnunen U-M, Kivekäs E, Palojoki S, et al. Register-based research of adverse events revealing incomplete records threatening patient safety. Stud Health Technol Info…
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psnet.ahrq.gov/issue/its-all-about-patient-safety-ethnographic-study-how-pharmacy-staff-construct-medicines-safety
October 06, 2021 - Study
'It's all about patient safety': an ethnographic study of how pharmacy staff construct medicines safety in the context of polypharmacy.
Citation Text:
Fudge N, Swinglehurst D. ‘It's all about patient safety’: an ethnographic study of how pharmacy staff construct medicines safety in…
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
View more articles from the same authors.
Citation Text:
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
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psnet.ahrq.gov/perspective/conversation-lorri-zipperer-ma
February 26, 2025 - In Conversation With… Lorri Zipperer, MA
November 1, 2015
Citation Text:
In Conversation With… Lorri Zipperer, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/49631/psn-pdf
July 01, 2011 - Patient Safety and Adherence to Self-Administered
Medications
July 1, 2011
Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications.
PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
The Case
A 30-year-o…
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psnet.ahrq.gov/node/33687/psn-pdf
August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health
Care
August 1, 2009
Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
Perspective
Frontline health care providers are challen…
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psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
May 01, 2013 - But once you get beyond that, good reliable measures are hard to find. … If I could invest in one thing in patient safety, it would be in coming up with high-quality reliable