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psnet.ahrq.gov/node/867986/psn-pdf
March 24, 2025 - In Conversation with Edwin Boudreaux about Suicide
Prevention
March 24, 2025
Boudreaux E, Gale B, Mossburg SE. In Conversation with Edwin Boudreaux about Suicide Prevention.
PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention
Editor’s note: Edwin Boudre…
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psnet.ahrq.gov/innovation/implementing-watcher-program-improve-timeliness-recognition-deterioration-hospitalized
June 30, 2021 - EMERGING INNOVATIONS
Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children
Citation Text:
Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children Evans S, Green A, Roberson A, et al. …
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psnet.ahrq.gov/issue/using-harm-based-weights-ahrq-patient-safety-selected-indicators-composite-psi-90-does-it
March 15, 2016 - Study
Using harm-based weights for the AHRQ Patient Safety for Selected Indicators composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health Administration hospitals?
Citation Text:
Chen Q, Rosen AK, Borzecki A, et al. Using Harm-Bas…
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psnet.ahrq.gov/innovation/awareness-human-factors-operating-theatres-during-covid-19-pandemic
January 13, 2021 - EMERGING INNOVATIONS
Awareness of human factors in the operating theatres during the COVID-19 pandemic
Citation Text:
Britton CR, Hayman G, Stroud N. Awareness of Human Factors in the operating theatres during the COVID-19 pandemic. Journal of Perioperative Practice. 2020;31(1-2). doi:10.1177/1750…
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psnet.ahrq.gov/node/865718/psn-pdf
May 01, 2024 - Calculating the cost of medication errors: a systematic
review of approaches and cost variables.
May 1, 2024
Ranasinghe S, Nadeshkumar A, Senadheera S, et al. Calculating the cost of medication errors: a
systematic review of approaches and cost variables. BMJ Open Qual. 2024;13(2):e002570.
doi:10.1136/bmjoq-2023-0…
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psnet.ahrq.gov/node/50907/psn-pdf
February 19, 2020 - Oral chemotherapy: a home safety educational framework
for healthcare providers, patients, and caregivers.
February 19, 2020
Huff C. Oral chemotherapy: A home safety educational framework for healthcare providers, patients, and
caregivers. Clin J Oncol Nurs. 2020;24(1):22-30. doi:10.1188/20.cjon.22-30.
https://psn…
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psnet.ahrq.gov/node/47119/psn-pdf
September 19, 2018 - A usability and safety analysis of electronic health
records: a multi-center study.
September 19, 2018
Ratwani RM, Savage E, Will A, et al. A usability and safety analysis of electronic health records: a multi-
center study. J Am Med Inform Assoc. 2018;25(9):1197-1201. doi:10.1093/jamia/ocy088.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/43153/psn-pdf
May 07, 2014 - Is oral chemotherapy prescription safe for patients? A
cross-sectional survey.
May 7, 2014
Bourmaud A, Pacaut C, Melis A, et al. Is oral chemotherapy prescription safe for patients? A cross-
sectional survey. Ann Oncol. 2014;25(2):500-504. doi:10.1093/annonc/mdt553.
https://psnet.ahrq.gov/issue/oral-chemotherapy-p…
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psnet.ahrq.gov/node/848088/psn-pdf
April 26, 2023 - Safety Risk of Air Embolus Associated with Central
Venous Catheters Used for Haemodialysis Treatment.
April 26, 2023
Farnborough, UK: Healthcare Safety Investigation Branch. March 2023.
https://psnet.ahrq.gov/issue/safety-risk-air-embolus-associated-central-venous-catheters-used-
haemodialysis-treatment
Patients …
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psnet.ahrq.gov/node/46676/psn-pdf
December 13, 2017 - Diagnostic errors by medical students: results of a
prospective qualitative study.
December 13, 2017
Braun LT, Zwaan L, Kiesewetter J, et al. Diagnostic errors by medical students: results of a prospective
qualitative study. BMC Med Educ. 2017;17(1):191. doi:10.1186/s12909-017-1044-7.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/45253/psn-pdf
October 03, 2017 - Patient safety: disclosure of medical errors and risk
mitigation.
October 3, 2017
Moffatt-Bruce SD, Ferdinand FD, Fann J. Patient Safety: Disclosure of Medical Errors and Risk Mitigation.
Ann Thorac Surg. 2016;102(2):358-62. doi:10.1016/j.athoracsur.2016.06.033.
https://psnet.ahrq.gov/issue/patient-safety-disclosu…
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psnet.ahrq.gov/node/44772/psn-pdf
January 13, 2016 - Post event debriefs: a commitment to learning how to
better care for patients and staff.
January 13, 2016
Campbell M, Miller K, McNicholas KW. Post Event Debriefs: A Commitment to Learning How to Better Care
for Patients and Staff. Jt Comm J Qual Patient Saf. 2016;42(1):41-47.
https://psnet.ahrq.gov/issue/post-eve…
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psnet.ahrq.gov/node/42672/psn-pdf
October 23, 2013 - SBAR improves nurse–physician communication and
reduces unexpected death: a pre and post intervention
study.
October 23, 2013
De Meester K, Verspuy M, Monsieurs KG, et al. SBAR improves nurse-physician communication and
reduces unexpected death: a pre and post intervention study. Resuscitation. 2013;84(9):1192-6.
…
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psnet.ahrq.gov/node/866561/psn-pdf
August 21, 2024 - Medical malpractice litigation and daylight saving time.
August 21, 2024
Gao C, Lage C, Scullin MK. Medical malpractice litigation and daylight saving time. J Clin Sleep Med.
2024;20(6):933-940. doi:10.5664/jcsm.11038.
https://psnet.ahrq.gov/issue/medical-malpractice-litigation-and-daylight-saving-time
Sleep depri…
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psnet.ahrq.gov/node/45246/psn-pdf
August 15, 2016 - Reliability of verbal handoff assessment and handoff
quality before and after implementation of a resident
handoff bundle.
August 15, 2016
Feraco AM, Starmer AJ, Sectish TC, et al. Reliability of Verbal Handoff Assessment and Handoff Quality
Before and After Implementation of a Resident Handoff Bundle. Acad Pediat…
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psnet.ahrq.gov/node/35990/psn-pdf
September 17, 2010 - Misunderstanding of prescription drug warning labels
among patients with low literacy.
September 17, 2010
Wolf MS, Davis TC, Tilson HH, et al. Misunderstanding of prescription drug warning labels among patients
with low literacy. Am J Health Syst Pharm. 2006;63(11):1048-55.
https://psnet.ahrq.gov/issue/misundersta…
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psnet.ahrq.gov/node/38228/psn-pdf
July 14, 2010 - Timely follow-up of abnormal outpatient test results:
perceived barriers and impact on patient safety.
July 14, 2010
Moore C, Saigh O, Trikha A, et al. Timely Follow-Up of Abnormal Outpatient Test Results. J Patient Saf.
2008;4(4):241-244. doi:10.1097/pts.0b013e31818d1ca4.
https://psnet.ahrq.gov/issue/timely-follo…
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psnet.ahrq.gov/node/40343/psn-pdf
December 21, 2014 - Trends in central line–associated bloodstream infections
in a trauma-surgical intensive care unit.
December 21, 2014
Ong A, Dysert K, Herbert C, et al. Trends in central line-associated bloodstream infections in a trauma-
surgical intensive care unit. Arch Surg. 2011;146(3):302-7. doi:10.1001/archsurg.2011.9.
http…
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psnet.ahrq.gov/node/47503/psn-pdf
October 24, 2018 - I-PASS checklist: a powerful tool for patient handoffs.
October 24, 2018
Peeples L. Pharmacy Practice News. October 10, 2018.
https://psnet.ahrq.gov/issue/i-pass-checklist-powerful-tool-patient-handoffs
Structured handoffs can reduce communication problems that contribute to medical error. This magazine
article re…
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psnet.ahrq.gov/node/855438/psn-pdf
November 15, 2023 - Intravenous (IV) push medications – bridging the gap
between education and clinical practice.
November 15, 2023
ISMP Medication Safety Alert! Acute Care. November 2, 2023;28(22):1-4.
https://psnet.ahrq.gov/issue/intravenous-iv-push-medications-bridging-gap-between-education-and-clinical-
practice
Intravenous…