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psnet.ahrq.gov/node/43943/psn-pdf
December 04, 2015 - Culture Change in the NHS: Applying the Lessons of the
Francis Inquiries.
December 4, 2015
Department of Health. London, England: Crown Publishing; February 2015. ISBN: 9781474112116.
https://psnet.ahrq.gov/issue/culture-change-nhs-applying-lessons-francis-inquiries
The Francis inquiry uncovered numerous problems …
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psnet.ahrq.gov/node/50891/psn-pdf
February 12, 2020 - Nurses as antimicrobial stewards: recognition,
confidence, and organizational factors across nine
hospitals.
February 12, 2020
Monsees E, Goldman J, Vogelsmeier A, et al. Nurses as antimicrobial stewards: Recognition, confidence,
and organizational factors across nine hospitals. Am J Infect Control. 2020. doi:10.1…
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psnet.ahrq.gov/node/42605/psn-pdf
December 16, 2013 - The "hidden curriculum" and residents' attitudes about
medical error disclosure: comparison of surgical and
nonsurgical residents.
December 16, 2013
Martinez W, Lehmann LS. The "hidden curriculum" and residents' attitudes about medical error disclosure:
comparison of surgical and nonsurgical residents. J Am Coll S…
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psnet.ahrq.gov/node/866285/psn-pdf
October 30, 2023 - Executive Order on the Safe, Secure, and Trustworthy
Development and Use of Artificial Intelligence.
October 30, 2023
Washington DC: The White House; October 30, 2023. EO 14110.
https://psnet.ahrq.gov/issue/executive-order-safe-secure-and-trustworthy-development-and-use-artificial-
intelligence
Artificial in…
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psnet.ahrq.gov/node/61097/psn-pdf
November 04, 2020 - Obstetrician-gynecologist views of pregnancy-related
medication safety.
November 4, 2020
SteelFisher GK, Hero JO, Caporello HL, et al. Obstetrician-gynecologist views of pregnancy-related
medication safety. J Womens Health (Larchmt). 2020;29(8):1113-1121. doi:10.1089/jwh.2019.8007.
https://psnet.ahrq.gov/issue/obs…
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psnet.ahrq.gov/node/41215/psn-pdf
September 04, 2013 - Medical emergency team calls in the radiology
department: patient characteristics and outcomes.
September 4, 2013
Ott LK, Pinsky MR, Hoffman LA, et al. Medical emergency team calls in the radiology department: patient
characteristics and outcomes. BMJ Qual Saf. 2012;21(6):509-18. doi:10.1136/bmjqs-2011-000423.
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August 28, 2019 - Error Reduction and Prevention in Surgical Pathology,
Second Edition.
August 28, 2019
Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.
https://psnet.ahrq.gov/issue/error-reduction-and-prevention-surgical-pathology-2nd-edition
Surgical specimen and laboratory process proble…
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psnet.ahrq.gov/node/60949/psn-pdf
September 23, 2020 - Why accountability sharing in health care organizational
cultures means patients are probably safer.
September 23, 2020
Eng DM, Schweikart SJ. AMA J Ethics. 2020;22(9):e779-e783.
https://psnet.ahrq.gov/issue/why-accountability-sharing-health-care-organizational-cultures-means-
patients-are-probably
The recognitio…
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psnet.ahrq.gov/node/47623/psn-pdf
February 06, 2019 - Diagnostic heuristics in dermatology—part 1 and part 2.
February 6, 2019
Lowenstein EJ, Sidlow R. Cognitive and visual diagnostic errors in dermatology: part 1 and part 2. J
Dermatol. 2018;179(6):1263-1276. doi:10.1111/bjd.16932.
https://psnet.ahrq.gov/issue/diagnostic-heuristics-dermatology-part-1-and-part-2
Cogn…
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psnet.ahrq.gov/node/45028/psn-pdf
May 25, 2016 - 'Just culture': improving safety by achieving substantive,
procedural and restorative justice.
May 25, 2016
Dekker SWA, Breakey H. ‘Just culture:’ Improving safety by achieving substantive, procedural and
restorative justice. Saf Sci. 2016;85. doi:10.1016/j.ssci.2016.01.018.
https://psnet.ahrq.gov/issue/just-cultu…
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psnet.ahrq.gov/node/60718/psn-pdf
July 22, 2020 - First Do No Harm. The Report of the Independent
Medicines and Medical Devices Safety Review.
July 22, 2020
Cumberlege J. London, England, Crown Copyright. July 8, 2020.
https://psnet.ahrq.gov/issue/first-do-no-harm-report-independent-medicines-and-medical-devices-safety-
review
Implicit biases are known to affect…
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psnet.ahrq.gov/node/854382/psn-pdf
October 11, 2023 - Battling alarm fatigue in the pediatric intensive care unit.
October 11, 2023
Herrera H, Wood D. Battling alarm fatigue in the pediatric intensive care unit. Crit Care Nurs Clin North Am.
2023;35(3):347-355. doi:10.1016/j.cnc.2023.05.003.
https://psnet.ahrq.gov/issue/battling-alarm-fatigue-pediatric-intensive-care-…
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psnet.ahrq.gov/node/45423/psn-pdf
September 27, 2016 - Lost in translation: impact of language barriers on
children's healthcare.
September 27, 2016
Goenka PK. Lost in translation: impact of language barriers on children's healthcare. Curr Opin Pediatr.
2016;28(5):659-666. doi:10.1097/MOP.0000000000000404.
https://psnet.ahrq.gov/issue/lost-translation-impact-language-…
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psnet.ahrq.gov/node/35899/psn-pdf
January 02, 2017 - Labeling solutions and medications in sterile procedural
settings.
January 2, 2017
Sheridan DJ. Labeling solutions and medications in sterile procedural settings. Jt Comm J Qual Patient
Saf. 2006;32(5):276-82.
https://psnet.ahrq.gov/issue/labeling-solutions-and-medications-sterile-procedural-settings
In response …
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psnet.ahrq.gov/node/850176/psn-pdf
June 07, 2023 - Care Post-Roe: Documenting Cases of Poor-quality Care
Since the Dobbs Decision.
June 7, 2023
Grossman D, Joffe C, Kaller S, et al. Advancing New Standards in Reproductive Health, University of
California, San Francisco; 2023.
https://psnet.ahrq.gov/issue/care-post-roe-documenting-cases-poor-quality-care-dobbs-deci…
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psnet.ahrq.gov/node/850929/psn-pdf
June 21, 2023 - Requirements for implementing a 'just culture' within
healthcare organisations: an integrative review.
June 21, 2023
Murray JS, Lee J, Larson S, et al. Requirements for implementing a ‘just culture’ within healthcare
organisations: an integrative review. BMJ Open Qual. 2023;12(2):e002237. doi:10.1136/bmjoq-2022-
0…
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psnet.ahrq.gov/node/34885/psn-pdf
February 07, 2019 - Doctor’s orders killed cancer patient: Dana-Farber admits
drug overdose caused death of Globe columnist, damage
to second woman.
February 7, 2019
Knox RA. Boston Globe. March 23, 1995; metro/region:1.
https://psnet.ahrq.gov/issue/doctors-orders-killed-cancer-patient-dana-farber-admits-drug-overdose-
caused-death-…
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psnet.ahrq.gov/node/73185/psn-pdf
April 28, 2021 - Balancing patient safety, clinical efficacy, and
cybersecurity with clinician partners.
April 28, 2021
Schneider J, Wirth A. Balancing patient safety, clinical efficacy, and cybersecurity with clinician partners.
Biomed Instrum Technol. 2021;55(1):21-28. doi:10.2345/0899-8205-55.1.21.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/60592/psn-pdf
June 17, 2020 - African American COVID-19 mortality: a sentinel event.
June 17, 2020
Ferdinand KC, Nasser SA. African American COVID-19 mortality: a sentinel event. J Am Coll Cardiol.
2020;75(21):2746-2748. doi:10.1016/j.jacc.2020.04.040.
https://psnet.ahrq.gov/issue/african-american-covid-19-mortality-sentinel-event
The authors …
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psnet.ahrq.gov/node/35356/psn-pdf
May 27, 2011 - Computerized physician order entry, a factor in
medication errors: descriptive analysis of events in the
intensive care unit safety reporting system.
May 27, 2011
Thompson DA; Duling L; Holzmueller CG; et al. JCOM. 2(8):407-412
https://psnet.ahrq.gov/issue/computerized-physician-order-entry-factor-medication-error…