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psnet.ahrq.gov/node/849133/psn-pdf
May 17, 2023 - The association between patient safety culture and
adverse events - a scoping review.
May 17, 2023
Vikan M, Haugen AS, Bjørnnes AK, et al. The association between patient safety culture and adverse
events – a scoping review. BMC Health Serv Res. 2023;23(1):300. doi:10.1186/s12913-023-09332-8.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/73407/psn-pdf
June 16, 2021 - Common Formats for Patient Safety Data Collection:
Diagnostic Safety 0.1.
June 16, 2021
The Agency for Healthcare Research and Quality. Fed Register. 2021;86(103): 29263-29264.
https://psnet.ahrq.gov/issue/common-formats-patient-safety-data-collection-diagnostic-safety-01
Measurement of diagnostic errors is an imp…
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psnet.ahrq.gov/node/854625/psn-pdf
January 01, 2024 - Remote patient monitoring improves patient falls and
reduces harm.
October 18, 2023
Zimbro KS, Bridges C, Bunn S, et al. Remote patient monitoring improves patient falls and reduces harm. J
Nurs Care Qual. 2024;39(3):212-219. doi:10.1097/ncq.0000000000000749.
https://psnet.ahrq.gov/issue/remote-patient-monitoring-…
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psnet.ahrq.gov/node/38301/psn-pdf
February 15, 2011 - Defining the incidence of cardiorespiratory instability in
patients in step-down units using an electronic integrated
monitoring system.
February 15, 2011
Hravnak M, Edwards L, Clontz A, et al. Defining the incidence of cardiorespiratory instability in patients in
step-down units using an electronic integrated mon…
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psnet.ahrq.gov/node/74042/psn-pdf
November 03, 2021 - An Investigation into the Death of Baby J at University
Hospitals Bristol and Weston NHS Foundation Trust.
November 3, 2021
Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021.
https://psnet.ahrq.gov/issue/investigation-death-baby-j-university-hospitals-bristol-and-weston-nhs-
foundation-trust…
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psnet.ahrq.gov/node/837701/psn-pdf
July 20, 2022 - Pediatric surgical errors: a systematic scoping review.
July 20, 2022
Marsh KM, Fleming MA, Turrentine FE, et al. Pediatric surgical errors: a systematic scoping review. J
Pediatr Surg. 2022;57(4):616-621. doi:10.1016/j.jpedsurg.2021.07.019.
https://psnet.ahrq.gov/issue/pediatric-surgical-errors-systematic-scoping-…
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psnet.ahrq.gov/node/845276/psn-pdf
March 01, 2023 - Cognitive biases in surgery: systematic review.
March 1, 2023
Armstrong BA, Dutescu IA, Tung A, et al. Cognitive biases in surgery: systematic review. Br J Surg.
2023;110(6):645-654. doi:10.1093/bjs/znad004.
https://psnet.ahrq.gov/issue/cognitive-biases-surgery-systematic-review
Cognitive biases are a known source…
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psnet.ahrq.gov/node/44443/psn-pdf
September 09, 2015 - Using multidisciplinary rounds to improve patient safety
through venous thromboembolism prevention awareness.
September 9, 2015
Karasin B, Maund C. Using Multidisciplinary Rounds to Improve Patient Safety Through Venous
Thromboembolism Prevention Awareness. Jt Comm J Qual Patient Saf. 2015;41(9):428-431.
https://p…
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psnet.ahrq.gov/node/50428/psn-pdf
September 04, 2019 - Patient safety incidents caused by poor quality surgical
instruments.
September 4, 2019
Dominguez ED, Rocos B. Patient Safety Incidents Caused by Poor Quality Surgical Instruments. Cureus.
2019;11(6):e4877. doi:10.7759/cureus.4877.
https://psnet.ahrq.gov/issue/patient-safety-incidents-caused-poor-quality-surgical-…
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psnet.ahrq.gov/node/72582/psn-pdf
December 16, 2020 - Deficiencies in the Veterans Crisis Line Response to a
Veteran Caller Who Died.
December 16, 2020
Washington, DC: Department of Veterans Affairs, Office of Inspector General; November 17, 2020. Report
No 19-08542-11.
https://psnet.ahrq.gov/issue/deficiencies-veterans-crisis-line-response-veteran-caller-who-died
I…
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psnet.ahrq.gov/node/40745/psn-pdf
September 07, 2011 - A prospective observational study of physician handoff
for intensive-care-unit-to-ward patient transfers.
September 7, 2011
Li P, Stelfox HT, Ghali WA. A Prospective Observational Study of Physician Handoff for Intensive-Care-
Unit-to-Ward Patient Transfers. Am J Med. 2011;124(9). doi:10.1016/j.amjmed.2011.04.027.
…
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psnet.ahrq.gov/node/43639/psn-pdf
October 29, 2014 - Ebola case raises concern about everyday hospital
safety.
October 29, 2014
Rodricks D. Baltimore Sun. October 14, 2014.
https://psnet.ahrq.gov/issue/ebola-case-raises-concern-about-everyday-hospital-safety
Although significant progress has been made in improving patient safety over the past decade, many
medical e…
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psnet.ahrq.gov/node/45673/psn-pdf
December 07, 2016 - Report on the Safe Use of Pick Lists in Ambulatory Care
Settings.
December 7, 2016
Rizk S, Oguntebi G, Graber ML, Johnston D. Research Triangle Park, NC: RTI International; 2016.
https://psnet.ahrq.gov/issue/report-safe-use-pick-lists-ambulatory-care-settings
Standard term selection tools—like pick lists or drop-d…
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psnet.ahrq.gov/node/44326/psn-pdf
October 21, 2015 - Safety first! Using a checklist for intrafacility transport of
adult intensive care patients.
October 21, 2015
Comeau OY, Armendariz-Batiste J, Woodby SA. Safety First! Using a Checklist for Intrafacility Transport of
Adult Intensive Care Patients. Crit Care Nurse. 2015;35(5):16-25. doi:10.4037/ccn2015991.
https:/…
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psnet.ahrq.gov/node/43640/psn-pdf
November 12, 2014 - Infection prevention in the emergency department.
November 12, 2014
Liang SY, Theodoro DL, Schuur JD, et al. Infection prevention in the emergency department. Ann Emerg
Med. 2014;64(3):299-313. doi:10.1016/j.annemergmed.2014.02.024.
https://psnet.ahrq.gov/issue/infection-prevention-emergency-department
Emergency c…
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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/38663/psn-pdf
May 27, 2009 - Prevention of retained surgical sponges: a decision-
analytic model predicting relative cost-effectiveness.
May 27, 2009
Regenbogen SE, Greenberg CC, Resch SC, et al. Prevention of retained surgical sponges: a decision-
analytic model predicting relative cost-effectiveness. Surgery. 2009;145(5):527-35.
doi:10.1016…
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psnet.ahrq.gov/node/44002/psn-pdf
March 25, 2015 - Preventing medication errors in transitions of care: a
patient case approach.
March 25, 2015
Johnson A, Guirguis E, Grace Y. Preventing medication errors in transitions of care: A patient case
approach. J Am Pharm Assoc (2003). 2015;55(2):e264-276. doi:10.1331/JAPhA.2015.15509.
https://psnet.ahrq.gov/issue/prevent…
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psnet.ahrq.gov/node/49406/psn-pdf
June 01, 2003 - Continuous observation procedures for psychiatric wards lack standardization and use inconsistent
terminology
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psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - curvature around the wrist.12 Reasons for
variance in EKG systems within hospital systems include lack of standardization