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psnet.ahrq.gov/node/841481/psn-pdf
January 01, 2023 - Trainees' perceptions of being allowed to fail in clinical
training: a sense-making model.
December 14, 2022
Klasen JM, Teunissen PW, Driessen E, et al. Trainees' perceptions of being allowed to fail in clinical
training: a sense?making model. Med Educ. 2023;57(5):430-439. doi:10.1111/medu.14966.
https://psnet.ahr…
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psnet.ahrq.gov/node/47956/psn-pdf
June 26, 2019 - Family involvement in managing medications of older
patients across transitions of care: a systematic review.
June 26, 2019
Manias E, Bucknall T, Hughes C, et al. Family involvement in managing medications of older patients
across transitions of care: a systematic review. BMC Geriatr. 2019;19(1):95. doi:10.1186/s12…
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psnet.ahrq.gov/node/46397/psn-pdf
August 30, 2017 - Making Dialysis Safer for Patients Coalition.
August 30, 2017
Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/making-dialysis-safer-patients-coalition
Dialysis is a common procedure that carries risks if not performed correctly. This initiative represents a
collective effort that aims to d…
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psnet.ahrq.gov/node/867133/psn-pdf
November 13, 2024 - Designing an intervention to improve medication safety
for nursing home residents based on experiential
knowledge related to patient safety culture at the nursing
home front line: cocreative process study.
November 13, 2024
Juhl MH, Soerensen AL, Vardinghus-Nielsen H, et al. Designing an intervention to improve me…
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psnet.ahrq.gov/node/866692/psn-pdf
September 11, 2024 - Relationships between medications used in a mental
health hospital and types of medication errors: a cross-
sectional study over an 8-year period.
September 11, 2024
Lebas R, Calvet B, Schadler L, et al. Relationships between medications used in a mental health hospital
and types of medication errors: a cross-sect…
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psnet.ahrq.gov/node/837501/psn-pdf
June 22, 2022 - Development and validation of a brief culture-of-safety
survey.
June 22, 2022
Barnard C, Chung JW, Flaherty V, et al. Development and validation of a brief culture-of-safety survey. Jt
Comm J Qual Patient Saf. 2022;48(9):430-438. doi:10.1016/j.jcjq.2022.04.006.
https://psnet.ahrq.gov/issue/development-and-validati…
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psnet.ahrq.gov/node/47859/psn-pdf
May 15, 2019 - The design and conduct of Project RedDE: a cluster-
randomized trial to reduce diagnostic errors in pediatric
primary care.
May 15, 2019
Bundy DG, Singh H, Stein RE, et al. The design and conduct of Project RedDE: A cluster-randomized trial
to reduce diagnostic errors in pediatric primary care. Clin Trials. 2019;1…
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psnet.ahrq.gov/node/837070/psn-pdf
May 11, 2022 - Patient falls in the operating room setting: an analysis of
reported safety events.
May 11, 2022
Tan J, Krishnan S, Vacanti JC, et al. Patient falls in the operating room setting: an analysis of reported
safety events. J Healthc Risk Manag. 2022;42(1):9-14. doi:10.1002/jhrm.21503.
https://psnet.ahrq.gov/issue/pati…
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psnet.ahrq.gov/node/47912/psn-pdf
April 24, 2019 - A systematic literature review and narrative synthesis on
the risks of medical discharge letters for patients' safety.
April 24, 2019
Schwarz CM, Hoffmann M, Schwarz P, et al. A systematic literature review and narrative synthesis on the
risks of medical discharge letters for patients' safety. BMC Health Serv Res. …
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psnet.ahrq.gov/node/73878/psn-pdf
September 29, 2021 - Interventions to improve communication at hospital
discharge and rates of readmission: a systematic review
and meta-analysis.
September 29, 2021
Becker C, Zumbrunn S, Beck K, et al. Interventions to improve communication at hospital discharge and
rates of readmission. JAMA Netw Open. 2021;4(8):e2119346. doi:10.100…
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psnet.ahrq.gov/node/34622/psn-pdf
March 17, 2011 - National Confidential Enquiry into Patient Outcome and
Death.
March 17, 2011
National Confidential Enquiry into Patient Outcome and Death; NCEPOD
https://psnet.ahrq.gov/issue/national-confidential-enquiry-patient-outcome-and-death
Launched under the title National Confidential Enquiry into Perioperative Deaths (NC…
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psnet.ahrq.gov/node/33892/psn-pdf
May 03, 2016 - Critical Incident Technique Bibliography—2001.
May 3, 2016
Fivars G; Fitzpatrick R
https://psnet.ahrq.gov/issue/critical-incident-technique-bibliography-2001
A research tool to identify critical requirements for performance in applied areas of psychology and
behavioral science. This technique, used in anesthesia t…
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psnet.ahrq.gov/node/45583/psn-pdf
January 18, 2017 - ASHP IV Adult Continuous Infusions.
January 18, 2017
Bethesda, MD: American Society of Health-System Pharmacists; 2016.
https://psnet.ahrq.gov/issue/ashp-iv-adult-continuous-infusions
Miscalculations of intravenous infusion concentrations can result in patient harm. Representing the first
phase of a standards deve…
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psnet.ahrq.gov/node/33914/psn-pdf
September 29, 2017 - Inpatient Quality Indicators.
September 29, 2017
Agency for Healthcare Research and Quality; AHRQ; University of California, San Francisco-Stanford
Evidence-based Practice Center.
https://psnet.ahrq.gov/issue/inpatient-quality-indicators
The Agency for Healthcare Research and Quality's (AHRQ) Quality Indicators (Q…
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psnet.ahrq.gov/node/42601/psn-pdf
September 18, 2013 - 'You talking to me?' Docs and feedback.
September 18, 2013
Diamond F. 'You talking to me?' Docs and feedback. Managed care (Langhorne, Pa.). 2013;22(7):30-2.
https://psnet.ahrq.gov/issue/you-talking-me-docs-and-feedback
Reporting on barriers to teamwork, this magazine article relates how hierarchy influences speaki…
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psnet.ahrq.gov/node/36063/psn-pdf
December 23, 2012 - Oversight Hearing on Recent Patient Safety Issues.
December 23, 2012
U.S. Department of Veterans Affairs. Hearing before the Committee on Veterans’ Affairs, House of
Representatives, Subcommittee on Oversight and Investigations. 109 Congress, 2nd sess June 15, 2006.
Washington, DC: US Government Printing Office; 20…
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psnet.ahrq.gov/node/837512/psn-pdf
January 01, 2024 - Team cognition in handoffs: relating system factors, team
cognition functions and outcomes in two handoff
processes.
June 22, 2022
Wooldridge AR, Carayon P, Hoonakker PLT, et al. Team cognition in handoffs: relating system factors,
team cognition functions and outcomes in two handoff processes. Hum Factors. 2024;6…
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psnet.ahrq.gov/node/860724/psn-pdf
January 17, 2024 - Retrospective cohort study of wrong-patient imaging
order errors: how many reach the patient?
January 17, 2024
Kneifati-Hayek JZ, Geist E, Applebaum JR, et al. Retrospective cohort study of wrong-patient imaging
order errors: how many reach the patient? BMJ Qual Saf. 2024;33(2):132-135. doi:10.1136/bmjqs-2023-
016…
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psnet.ahrq.gov/node/837313/psn-pdf
June 01, 2022 - Are you well positioned to resolve conflicts with the
safety of an order? Learning from a physician’s homicide
trial and the firing of multiple healthcare workers.
June 1, 2022
ISMP Medication Safety Alert! Acute care edition. May 19, 2022;27(10):1-5.
https://psnet.ahrq.gov/issue/are-you-well-positioned-resolve-co…
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psnet.ahrq.gov/node/60532/psn-pdf
May 27, 2020 - Improving timely recognition and treatment of sepsis in
the pediatric ICU.
May 27, 2020
Vidrine R, Zackoff M, Paff Z, et al. Improving timely recognition and treatment of sepsis in the pediatric ICU.
Jt Comm J Qual Patient Saf. 2020;46(5):299-307. doi:10.1016/j.jcjq.2020.02.005.
https://psnet.ahrq.gov/issue/improv…