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psnet.ahrq.gov/node/34981/psn-pdf
July 14, 2010 - Child-specific risk factors and patient safety.
July 14, 2010
Woods DM, Holl JL, Shonkoff JP, et al. J Patient Saf. 2005;1(1):17-22.
https://psnet.ahrq.gov/issue/child-specific-risk-factors-and-patient-safety
To discover factors that may contribute to a child’s risk for error during hospitalization, this study iden…
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psnet.ahrq.gov/node/42436/psn-pdf
August 07, 2013 - Office-based physicians are responding to incentives and
assistance by adopting and using electronic health
records.
August 7, 2013
Hsiao C-J, Jha AK, King J, et al. Office-based physicians are responding to incentives and assistance by
adopting and using electronic health records. Health Aff (Millwood). 2013;32(8…
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psnet.ahrq.gov/node/43910/psn-pdf
November 23, 2016 - Error disclosure and family members' reactions: does the
type of error really matter?
November 23, 2016
Leone D, Lamiani G, Vegni E, et al. Error disclosure and family members' reactions: does the type of error
really matter? Patient Educ Couns. 2015;98(4):446-52. doi:10.1016/j.pec.2014.12.011.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/34809/psn-pdf
February 18, 2011 - Iatrogenic illness on a general medical service at a
university hospital.
February 18, 2011
Steel K, Gertman PM, Crescenzi C, et al. Iatrogenic illness on a general medical service at a university
hospital. N Engl J Med. 1981;304(11):638-42.
https://psnet.ahrq.gov/issue/iatrogenic-illness-general-medical-service-u…
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psnet.ahrq.gov/node/46742/psn-pdf
March 14, 2018 - Evidence-based guidelines for fatigue risk management in
emergency medical services.
March 14, 2018
Patterson D, Higgins S, Van Dongen HPA, et al. Evidence-Based Guidelines for Fatigue Risk Management
in Emergency Medical Services. Prehosp Emerg Care. 2018;22(sup1):89-101.
doi:10.1080/10903127.2017.1376137.
https…
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psnet.ahrq.gov/node/44946/psn-pdf
February 01, 2017 - Quality gaps identified through mortality review.
February 1, 2017
Kobewka DM, van Walraven C, Turnbull J, et al. Quality gaps identified through mortality review. BMJ Qual
Saf. 2017;26(2):141-149. doi:10.1136/bmjqs-2015-004735.
https://psnet.ahrq.gov/issue/quality-gaps-identified-through-mortality-review
Inpatien…
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psnet.ahrq.gov/node/41440/psn-pdf
August 17, 2016 - The Toolkit for Using the AHRQ Quality Indicators: How
To Improve Hospital Quality and Safety.
August 17, 2016
Rockville, MD: Agency for Healthcare Research and Quality; July 2016.
https://psnet.ahrq.gov/issue/toolkit-using-ahrq-quality-indicators-how-improve-hospital-quality-and-safety
This toolkit provides resou…
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psnet.ahrq.gov/node/853427/psn-pdf
January 01, 2024 - Patient and family contributions to improve the diagnostic
process through the OurDX electronic health record tool:
a mixed method analysis.
September 13, 2023
Bell SK, Harcourt K, Dong J, et al. Patient and family contributions to improve the diagnostic process
through the OurDX electronic health record tool: a m…
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psnet.ahrq.gov/node/49692/psn-pdf
September 01, 2013 - A Picture Speaks 1000 Words
September 1, 2013
Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/picture-speaks-1000-words
The Case
A 62-year-old man with a past medical history of hypertension, hyperlipidemia, and type A aortic dissection
repair presented with chest p…
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psnet.ahrq.gov/node/49421/psn-pdf
October 01, 2003 - Urine a Tough Position
October 1, 2003
Gandhi TK. Urine a Tough Position. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/urine-tough-position
The Case
A 22-year-old unmarried woman came to her doctor’s office worried that she might be pregnant. Although
she did not want to have a baby at that time, she sta…
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psnet.ahrq.gov/node/34797/psn-pdf
October 06, 2015 - Adapting to new technologies in the operating room.
October 6, 2015
Cook RI, Woods DD. Adapting to New Technology in the Operating Room. Hum Factors. 2006;38(4):593-
613. doi:10.1518/001872096778827224.
https://psnet.ahrq.gov/issue/adapting-new-technologies-operating-room
New technology continues to offer great ad…
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psnet.ahrq.gov/node/45468/psn-pdf
October 11, 2017 - Identification and characterization of adverse drug events
in primary care.
October 11, 2017
Trinkley KE, Weed HG, Beatty SJ, et al. Identification and Characterization of Adverse Drug Events in
Primary Care. Am J Med Qual. 2017;32(5):518-525. doi:10.1177/1062860616665695.
https://psnet.ahrq.gov/issue/identificati…
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psnet.ahrq.gov/node/46977/psn-pdf
April 04, 2018 - Latex: a lingering and lurking safety risk.
April 4, 2018
Liberatore K. PA-PSRS Patient Saf Advis. 2018 March;15.
https://psnet.ahrq.gov/issue/latex-lingering-and-lurking-safety-risk
Latex products are widely available in hospitals and represent a persistent threat to patients with latex
allergies. Drawing from 61…
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psnet.ahrq.gov/node/36086/psn-pdf
June 14, 2011 - Sensemaking of patient safety risks and hazards.
June 14, 2011
Battles J, Dixon NM, Borotkanics RJ, et al. Sensemaking of patient safety risks and hazards. Health Serv
Res. 2006;41(4 Pt 2):1555-1575.
https://psnet.ahrq.gov/issue/sensemaking-patient-safety-risks-and-hazards
This commentary discusses the concept of …
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psnet.ahrq.gov/node/35127/psn-pdf
February 24, 2011 - Beyond the medical record: other modes of error
acknowledgment.
February 24, 2011
Rosenthal M, Cornett PL, Sutcliffe K, et al. Beyond the medical record: other modes of error
acknowledgment. J Gen Intern Med. 2005;20(5):404-9.
https://psnet.ahrq.gov/issue/beyond-medical-record-other-modes-error-acknowledgment
Thi…
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psnet.ahrq.gov/node/34676/psn-pdf
December 23, 2008 - Driving improvement in patient care: lessons from
Toyota.
December 23, 2008
Thompson DN, Wolf GA, Spear SJ. Driving improvement in patient care: lessons from Toyota. J Nurs Adm.
2003;33(11):585-595.
https://psnet.ahrq.gov/issue/driving-improvement-patient-care-lessons-toyota
Representatives from University of Pit…
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psnet.ahrq.gov/node/50702/psn-pdf
December 04, 2019 - Smart pumps improve medication safety but increase
alert burden in neonatal care
December 4, 2019
Melton KR, Timmons K, Walsh KE, et al. Smart pumps improve medication safety but increase alert burden
in neonatal care. BMC Medical Inform Decis Mak. 2019;19(1):213. doi:10.1186/s12911-019-0945-2.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/850916/psn-pdf
June 21, 2023 - Awareness of racial and ethnic bias and potential
solutions to address bias with use of health care
algorithms.
June 21, 2023
Jain A, Brooks JR, Alford CC, et al. Awareness of racial and ethnic bias and potential solutions to address
bias with use of health care algorithms. JAMA Health Forum. 2023;4(6):e231197.
d…
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psnet.ahrq.gov/node/48123/psn-pdf
August 28, 2019 - Hidden health IT hazards: a qualitative analysis of
clinically meaningful documentation discrepancies at
transfer out of the pediatric intensive care unit.
August 28, 2019
Orenstein EW, Ferro DF, Bonafide CP, et al. JAMIA Open. 2019;2(3):392-398.
https://psnet.ahrq.gov/issue/hidden-health-it-hazards-qualitative-an…
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psnet.ahrq.gov/node/50863/psn-pdf
February 05, 2020 - Patient safety in inpatient mental health settings: a
systematic review.
February 5, 2020
Thibaut BI, Dewa LH, Ramtale SC, et al. Patient safety in inpatient mental health settings: a systematic
review. BMJ Open. 2019;9(12):e030230. doi:10.1136/bmjopen-2019-030230.
https://psnet.ahrq.gov/issue/patient-safety-inpat…