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psnet.ahrq.gov/node/72682/psn-pdf
January 27, 2021 - Healthcare failure mode and effect analysis (HFMEA) as
an effective mechanism in preventing infection caused by
accompanying caregivers during COVID-19-experience of
a city medical center in Taiwan.
January 27, 2021
Tiao C-H, Tsai L-C, Chen L-C, et al. Healthcare Failure Mode and Effect Analysis (HFMEA) as an Effe…
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psnet.ahrq.gov/node/60645/psn-pdf
July 01, 2020 - How health care systems let our patients down: a
systematic review into suicide deaths.
July 1, 2020
Wyder M, Ray MK, Roennfeldt H, et al. How health care systems let our patients down: a systematic review
into suicide deaths. Int J Qual Health Care. 2020;32(5):285-291. doi:10.1093/intqhc/mzaa011.
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June 24, 2020 - Communication with health care workers regarding health
care-associated exposure to coronavirus 2019: a
checklist to facilitate disclosure.
June 24, 2020
Wickner PG, Hartley T, Salmasian H, et al. Communication with health care workers regarding health care-
associated exposure to coronavirus 2019: a checklist to …
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psnet.ahrq.gov/node/844991/psn-pdf
February 22, 2023 - Is anybody 'Learning' from deaths? Sequential content
and reflexive thematic analysis of national statutory
reporting within the NHS in England 2017-2020.
February 22, 2023
Brummell Z, Braun D, Hussein Z, et al. Is anybody ‘Learning’ from deaths? Sequential content and reflexive
thematic analysis of national statu…
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psnet.ahrq.gov/node/34792/psn-pdf
January 01, 2011 - Physician knowledge, attitudes, and behavior related to
reporting adverse drug events.
July 10, 2008
Rogers AS, Israel E, Smith CR, et al. Physician Knowledge, Attitudes, and Behavior Related to Reporting
Adverse Drug Events. Arch Intern Med. 2011;148(7):1596-1600.
doi:10.1001/archinte.1988.00380070090021.
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October 30, 2024 - From reporting to improving: how root cause analysis in
teams shape patient safety culture.
October 30, 2024
Tsamasiotis C, Fiard G, Bouzat P, et al. From reporting to improving: how root cause analysis in teams
shape patient safety culture. Risk Manag Healthc Policy. 2024;17:1847-1858. doi:10.2147/rmhp.s466852.
h…
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psnet.ahrq.gov/node/42542/psn-pdf
March 17, 2014 - Surgical checklists: a systematic review of impacts and
implementation.
March 17, 2014
Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation.
BMJ Qual Saf. 2014;23(4):299-318. doi:10.1136/bmjqs-2012-001797.
https://psnet.ahrq.gov/issue/surgical-checklists-systematic…
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psnet.ahrq.gov/node/855089/psn-pdf
January 01, 2024 - React, reframe and engage. Establishing a receiver
mindset for more effective safety negotiations.
November 8, 2023
Barlow M, Watson B, Morse K, et al. React, reframe and engage. Establishing a receiver mindset for more
effective safety negotiations. J Health Organ Manag. 2024;38(7):992-1008. doi:10.1108/jhom-06-20…
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April 01, 2020 - What every health lawyer should know about the Patient
Safety and Quality Improvement Act of 2005.
April 1, 2020
Hanzal M. What every health lawyer should know about the Patient Safety and Quality Improvement Act of
2005. J Health Life Sci Law. 2020;13(2):71-88.
https://psnet.ahrq.gov/issue/what-every-health-lawye…
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psnet.ahrq.gov/node/46981/psn-pdf
May 04, 2019 - Lessons learned from implementing a principled
approach to resolution following patient harm.
May 4, 2019
Smith KM, Smith LL, (Jack) Gentry JC, et al. Lessons learned from implementing a principled approach to
resolution following patient harm. J Patient Saf Risk Manag. 2018;24(2):83-89.
doi:10.1177/25160435188138…
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June 18, 2021 - Physical and verbal violence against health care workers.
June 18, 2021
Physical and verbal violence against health care workers. Sentinel Event Alert. 2018;59:1-9 (revised June
18, 2021).
https://psnet.ahrq.gov/issue/physical-and-verbal-violence-against-health-care-workers
The Joint Commission issues sentinel eve…
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psnet.ahrq.gov/node/42419/psn-pdf
July 17, 2013 - Health IT Patient Safety Action and Surveillance Plan.
July 17, 2013
Washington, DC: Office of the National Coordinator for Health Information Technology; July 2, 2013.
https://psnet.ahrq.gov/issue/health-it-patient-safety-action-and-surveillance-plan
This report from the Department of Health and Human Services (HH…
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psnet.ahrq.gov/node/47629/psn-pdf
July 11, 2019 - How not to waste a crisis: a qualitative study of problem
definition and its consequences in three hospitals.
July 11, 2019
Martin G, Ozieranski P, Leslie M, et al. How not to waste a crisis: a qualitative study of problem definition
and its consequences in three hospitals. J Health Serv Res Policy. 2019;24(3):145-…
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December 23, 2016 - Medical device alarm safety in hospitals.
December 23, 2016
Medical device alarm safety in hospitals. Sentinel event alert. 2013;(50):1-3.
https://psnet.ahrq.gov/issue/medical-device-alarm-safety-hospitals
The cacophony of alarms in hospitals has led many health care providers to become desensitized to them,
a con…
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August 09, 2023 - Factors influencing the perception of feeling safe in pre-
hospital emergency care: a mixed-methods systematic
review.
August 9, 2023
Péculo?Carrasco J?A, Luque?Hernández MJ, Rodríguez?Ruiz H?J, et al. Factors influencing the
perception of feeling safe in pre?hospital emergency care: a mixed?methods systematic rev…
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psnet.ahrq.gov/node/841148/psn-pdf
December 07, 2022 - How does workplace violence-reporting culture affect
workplace violence, nurse burnout, and patient safety?
December 7, 2022
Kim S, Lynn MR, Baernholdt MB, et al. How does workplace violence-reporting culture affect Workplace
violence, nurse burnout, and patient safety? J Nurs Care Qual. 2022;38(1):11-18.
doi:10.1…
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July 31, 2024 - Effect of digital tools to promote hospital quality and
safety on adverse events after discharge.
July 31, 2024
Vasudevan A, Plombon S, Piniella N, et al. Effect of digital tools to promote hospital quality and safety on
adverse events after discharge. J Am Med Inform Assoc. 2024;31(10):2304-2314.
doi:10.1093/jami…
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August 22, 2018 - Health IT Safe Practices for Closing the Loop.
August 22, 2018
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; August 2018.
https://psnet.ahrq.gov/issue/health-it-safe-practices-closing-loop
Inadequate follow-up of test results can contribute to missed and delayed diagnoses. Developing optimal…
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psnet.ahrq.gov/node/866401/psn-pdf
January 01, 2025 - Nurse judgements of hospitalized patients' safety
concerns are affected by patient, nurse and event
characteristics: a factorial survey experiment.
July 31, 2024
Groves PS, Farag A, Perkhounkova Y, et al. Nurse judgements of hospitalized patients' safety concerns
are affected by patient, nurse and event characteri…
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psnet.ahrq.gov/node/867336/psn-pdf
December 11, 2024 - Enhancing safe medication use in home care: insights
from informal caregivers.
December 11, 2024
Gil-Hernández E, Ballester P, Guilabert M, et al. Enhancing safe medication use in home care: insights
from informal caregivers. Front Med (Lausanne). 2024;11:1494771. doi:10.3389/fmed.2024.1494771.
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