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psnet.ahrq.gov/node/36804/psn-pdf
August 26, 2011 - Patterns of communication breakdowns resulting in injury
to surgical patients.
August 26, 2011
Greenberg CC, Regenbogen SE, Studdert DM, et al. Patterns of communication breakdowns resulting in
injury to surgical patients. J Am Coll Surg. 2007;204(4):533-40.
https://psnet.ahrq.gov/issue/patterns-communication-brea…
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www.ahrq.gov/topics/telehealth.html
Telehealth
AHRQ has invested in research and shared information on the benefits of telehealth for several years, through its Digital Healthcare Research Program and Effective Healthcare Program. Use of telehealth has expanded through advances in technology, availability of training, and improvemen…
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psnet.ahrq.gov/node/852288/psn-pdf
January 16, 2025 - Making Healthcare Safer IV: A Continuous Updating of
Patient Safety Harms and Practices.
January 16, 2025
Rockville, MD: Agency for Healthcare Research and Quality: July 2023 - Jan 2025.
https://psnet.ahrq.gov/issue/making-healthcare-safer-iv-continuous-updating-patient-safety-harms-and-
practices
Patient safety …
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psnet.ahrq.gov/node/865660/psn-pdf
April 24, 2024 - Comparing hospital leadership and front-line workers'
perceptions of patient safety culture: an unbalanced
panel study.
April 24, 2024
Forbes J, Arrieta A. Comparing hospital leadership and front-line workers’ perceptions of patient safety
culture: an unbalanced panel study. BMJ Lead. 2024;8(8):335-339. doi:10.113…
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psnet.ahrq.gov/node/46897/psn-pdf
October 13, 2018 - An assessment of the impact of just culture on quality
and safety in US hospitals.
October 13, 2018
Edwards MT. An Assessment of the Impact of Just Culture on Quality and Safety in US Hospitals. Am J
Med Qual. 2018;33(5):502-508. doi:10.1177/1062860618768057.
https://psnet.ahrq.gov/issue/assessment-impact-just-cul…
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psnet.ahrq.gov/node/43635/psn-pdf
November 12, 2014 - Electronic medical record: a balancing act of patient
safety, privacy and health care delivery.
November 12, 2014
Gummadi S, Housri N, Zimmers TA, et al. Electronic medical record: a balancing act of patient safety,
privacy and health care delivery. Am J Med Sci. 2014;348(3):238-243.
doi:10.1097/MAJ.00000000000002…
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psnet.ahrq.gov/node/46379/psn-pdf
December 22, 2018 - Primary care providers' opening of time-sensitive alerts
sent to commercial electronic health record InBaskets.
December 22, 2018
Cutrona SL, Fouayzi H, Burns L, et al. Primary Care Providers' Opening of Time-Sensitive Alerts Sent to
Commercial Electronic Health Record InBaskets. J Gen Intern Med. 2017;32(11):1210-…
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psnet.ahrq.gov/node/865870/psn-pdf
May 15, 2024 - Leading quality and safety on the frontline - a case study
of department leaders in nursing homes.
May 15, 2024
Magerøy M, Braut GS, Macrae C, et al. Leading quality and safety on the frontline - a case study of
department leaders in nursing homes. J Healthc Leadersh. 2024;16:193-208. doi:10.2147/jhl.s454109.
http…
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psnet.ahrq.gov/node/73983/psn-pdf
October 20, 2021 - Factors associated with potentially missed acute
deterioration in primary care: cohort study of UK general
practices.
October 20, 2021
Cecil E, Bottle A, Majeed A, et al. Factors associated with potentially missed acute deterioration in primary
care: cohort study of UK general practices. Br J Gen Pract. 2021;71(70…
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psnet.ahrq.gov/node/837795/psn-pdf
August 10, 2022 - Role of the regulator in enabling a just culture: a
qualitative study in mental health and hospital care.
August 10, 2022
Weenink J-W, Wallenburg I, Hartman L, et al. Role of the regulator in enabling a just culture: a qualitative
study in mental health and hospital care. BMJ Open. 2022;12(7):e061321. doi:10.1136/b…
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psnet.ahrq.gov/node/40524/psn-pdf
March 04, 2019 - Principles of pediatric patient safety: reducing harm due
to medical care.
March 4, 2019
Mueller BU, Neuspiel DR, Fisher ERS, et al. Principles of Pediatric Patient Safety: Reducing Harm Due to
Medical Care. Pediatrics. 2019;143(2):e20183649. doi:10.1542/peds.2018-3649.
https://psnet.ahrq.gov/issue/principles-pedi…
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psnet.ahrq.gov/node/74757/psn-pdf
February 09, 2022 - Characteristics of disease-specific and generic diagnostic
pitfalls: a qualitative study.
February 9, 2022
Schiff GD, Volodarskaya M, Ruan E, et al. Characteristics of disease-specific and generic diagnostic
pitfalls: a qualitative study. JAMA Netw Open. 2022;5(1):e2144531.
doi:10.1001/jamanetworkopen.2021.44531.
…
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psnet.ahrq.gov/node/854985/psn-pdf
November 01, 2023 - A systematic narrative review of coroners’ Prevention of
Future Deaths reports (PFDs): a tool for patient safety in
hospitals.
November 1, 2023
Bremner BT, Heneghan CJ, Aronson JK, et al. A systematic narrative review of coroners’ Prevention of
Future Deaths reports (PFDs): a tool for patient safety in hospitals. …
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psnet.ahrq.gov/node/837061/psn-pdf
May 11, 2022 - Nursing implications of an early warning system
implemented to reduce adverse events: a qualitative
study.
May 11, 2022
Braun EJ, Singh S, Penlesky AC, et al. Nursing implications of an early warning system implemented to
reduce adverse events: a qualitative study. BMJ Qual Saf. 2022;31(10):716-724. doi:10.1136/bm…
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psnet.ahrq.gov/node/40994/psn-pdf
December 18, 2014 - Implementing medication reconciliation in outpatient
pediatrics.
December 18, 2014
Rappaport DI, Collins B, Koster A, et al. Implementing medication reconciliation in outpatient pediatrics.
Pediatrics. 2011;128(6):e1600-7. doi:10.1542/peds.2011-0993.
https://psnet.ahrq.gov/issue/implementing-medication-reconciliat…
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psnet.ahrq.gov/node/48191/psn-pdf
August 28, 2019 - To catch a killer: electronic sepsis alert tools reaching a
fever pitch?
August 28, 2019
Ruppel H, Liu V. To catch a killer: electronic sepsis alert tools reaching a fever pitch? BMJ Qual Saf.
2019;28(9):693-696. doi:10.1136/bmjqs-2019-009463.
https://psnet.ahrq.gov/issue/catch-killer-electronic-sepsis-alert-tools…
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psnet.ahrq.gov/node/36237/psn-pdf
September 12, 2011 - An empirically derived taxonomy of factors affecting
physicians' willingness to disclose medical errors.
September 12, 2011
Kaldjian LC, Jones EW, Rosenthal GE, et al. An empirically derived taxonomy of factors affecting
physicians’ willingness to disclose medical errors. J Gen Intern Med. 2007;21(9). doi:10.1007/b…
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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.
https://psnet.ah…
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psnet.ahrq.gov/node/60055/psn-pdf
March 18, 2020 - A smartphone app designed to empower patients to
contribute toward safer surgical care: community-based
evaluation using a participatory approach.
March 18, 2020
Russ S, Latif Z, Hazell AL, et al. A Smartphone App Designed to Empower Patients to Contribute Toward
Safer Surgical Care: Community-Based Evaluation Usi…