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psnet.ahrq.gov/node/863212/psn-pdf
February 28, 2024 - unDerstandIng the cauSes of mediCation errOrs and
adVerse drug evEnts for patients with mental illness in
community caRe (DISCOVER): a qualitative study.
February 28, 2024
Ayre MJ, Lewis PJ, Phipps DL, et al. unDerstandIng the cauSes of mediCation errOrs and adVerse drug
evEnts for patients with mental illness in …
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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.
https:…
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psnet.ahrq.gov/node/867038/psn-pdf
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/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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psnet.ahrq.gov/node/60195/psn-pdf
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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psnet.ahrq.gov/node/47069/psn-pdf
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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psnet.ahrq.gov/node/36634/psn-pdf
March 03, 2011 - Surgeon information transfer and communication: factors
affecting quality and efficiency of inpatient care.
March 3, 2011
Williams RG, Silverman R, Schwind C, et al. Surgeon information transfer and communication: factors
affecting quality and efficiency of inpatient care. Ann Surg. 2007;245(2):159-69.
https://psn…
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psnet.ahrq.gov/node/42149/psn-pdf
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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psnet.ahrq.gov/node/852281/psn-pdf
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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psnet.ahrq.gov/node/866407/psn-pdf
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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psnet.ahrq.gov/node/47198/psn-pdf
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/856586/psn-pdf
November 29, 2023 - The complexities of communication at hospital discharge
of older patients: a qualitative study of healthcare
professionals' views.
November 29, 2023
Cam H, Wennlöf B, Gillespie U, et al. The complexities of communication at hospital discharge of older
patients: a qualitative study of healthcare professionals’ view…
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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.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/43663/psn-pdf
November 12, 2014 - On the CUSP: Stop BSI: evaluating the relationship
between central line–associated bloodstream infection
rate and patient safety climate profile.
November 12, 2014
Weaver SJ, Weeks K, Pham JC, et al. On the CUSP: Stop BSI: evaluating the relationship between central
line-associated bloodstream infection rate and p…