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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…
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psnet.ahrq.gov/node/43001/psn-pdf
March 19, 2014 - Variability in the measurement of hospital-wide mortality
rates.
March 19, 2014
Shahian DM, Wolf RE, Iezzoni LI, et al. Variability in the measurement of hospital-wide mortality rates. N
Engl J Med. 2010;363(26):2530-9. doi:10.1056/NEJMsa1006396.
https://psnet.ahrq.gov/issue/variability-measurement-hospital-wide-m…
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psnet.ahrq.gov/node/46289/psn-pdf
January 01, 2021 - Communication training, adverse events, and quality
measures: 2 retrospective database analyses in
Washington State hospitals.
August 9, 2017
Slade IR, Beck SJ, Kramer B, et al. Communication Training, Adverse Events, and Quality Measures: 2
Retrospective Database Analyses in Washington State Hospitals. J Patient …
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psnet.ahrq.gov/node/47979/psn-pdf
May 01, 2019 - Inpatient notes: just what the doctor ordered—checklists
to improve diagnosis.
May 1, 2019
Gupta A, Graber ML. Web Exclusive. Annals for Hospitalists Inpatient Notes - Just What the Doctor
Ordered-Checklists to Improve Diagnosis. Ann Intern Med. 2019;170(8):HO2-HO3. doi:10.7326/M19-0829.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/845649/psn-pdf
March 08, 2023 - Medication rounds: a tool to promote medication safety
for children with medical complexity.
March 8, 2023
Rojas CR, Moore A, Coffin A, et al. Medication rounds: a tool to promote medication safety for children with
medical complexity. Jt Comm J Qual Patient Saf. 2023;49(4):226-234. doi:10.1016/j.jcjq.2023.01.003.
…
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psnet.ahrq.gov/node/73995/psn-pdf
October 20, 2021 - Potential for medication overdose with ENFit low dose tip
syringe: FDA Safety Communication.
October 20, 2021
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 12, 2021.
https://psnet.ahrq.gov/issue/potential-medication-overdose-enfit-low-dose-tip-syringe-fda-safety-
communication
…
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psnet.ahrq.gov/node/45421/psn-pdf
December 14, 2016 - The medication reconciliation process and classification
of discrepancies: a systematic review.
December 14, 2016
Almanasreh E, Moles R, Chen TF. The medication reconciliation process and classification of
discrepancies: a systematic review. Br J Clin Pharmacol. 2016;82(3):645-658. doi:10.1111/bcp.13017.
https://p…
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psnet.ahrq.gov/node/45271/psn-pdf
August 10, 2016 - Patient identification and tube labelling—a call for
harmonisation.
August 10, 2016
van Dongen-Lases EC, Cornes MP, Grankvist K, et al. Patient identification and tube labelling – a call for
harmonisation. Clinical Chemistry and Laboratory Medicine (CCLM). 2016;54(7). doi:10.1515/cclm-2015-
1089.
https://psnet.ah…
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psnet.ahrq.gov/node/38873/psn-pdf
August 19, 2009 - What are covering doctors told about their patients?
Analysis of sign-out among internal medicine house staff.
August 19, 2009
Horwitz LI, Moin T, Krumholz HM, et al. What are covering doctors told about their patients? Analysis of
sign-out among internal medicine house staff. Qual Saf Health Care. 2009;18(4):248-5…
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psnet.ahrq.gov/node/72702/psn-pdf
February 03, 2021 - Outcomes from Wake Up Safe, the pediatric anesthesia
quality improvement initiative.
February 3, 2021
Haché M, Sun LS, Gadi G, et al. Outcomes from Wake Up Safe, the pediatric anesthesia quality
improvement initiative. Paediatr Anaesth. 2020;30(12):1348-1354. doi:10.1111/pan.14044.
https://psnet.ahrq.gov/issue/out…