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psnet.ahrq.gov/node/47304/psn-pdf
October 24, 2018 - Mind the overlap: how system problems contribute to
cognitive failure and diagnostic errors.
October 24, 2018
Gupta A, Harrod M, Quinn M, et al. Mind the overlap: how system problems contribute to cognitive failure
and diagnostic errors. Diagnosis (Berl). 2018;5(3):151-156. doi:10.1515/dx-2018-0014.
https://psnet.…
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psnet.ahrq.gov/node/48053/psn-pdf
July 17, 2019 - Review of medication errors that are new or likely to
occur more frequently with electronic medication
management systems.
July 17, 2019
Van de Vreede M, McGrath A, de Clifford J. Review of medication errors that are new or likely to occur
more frequently with electronic medication management systems. Aust Health …
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psnet.ahrq.gov/node/39264/psn-pdf
February 03, 2010 - Changing cardiac arrest and hospital mortality rates
through a medical emergency team takes time and
constant review.
February 3, 2010
Santamaria J, Tobin A, Holmes J. Changing cardiac arrest and hospital mortality rates through a medical
emergency team takes time and constant review. Crit Care Med. 2010;38(2):445…
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psnet.ahrq.gov/node/43500/psn-pdf
November 17, 2014 - A systematic review of behavioural marker systems in
healthcare: what do we know about their attributes,
validity and application?
November 17, 2014
Dietz AS, Pronovost P, Benson KN, et al. A systematic review of behavioural marker systems in
healthcare: what do we know about their attributes, validity and applica…
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psnet.ahrq.gov/node/45243/psn-pdf
September 14, 2016 - Incidence of speech recognition errors in the emergency
department.
September 14, 2016
Goss FR, Zhou L, Weiner SG. Incidence of speech recognition errors in the emergency department. Int J
Med Inform. 2016;93:70-73. doi:10.1016/j.ijmedinf.2016.05.005.
https://psnet.ahrq.gov/issue/incidence-speech-recognition-error…
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psnet.ahrq.gov/node/34665/psn-pdf
December 24, 2008 - Organizational learning: health care leaders need to
design structures and processes that enhance collective
learning.
December 24, 2008
Bohmer RM, Edmondson AC. Organizational learning in health care. Health Forum J. 2001;44(2):32-35.
https://psnet.ahrq.gov/issue/organizational-learning-health-care-leaders-need-d…
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psnet.ahrq.gov/node/44466/psn-pdf
September 16, 2015 - Is researching adverse events in hospital deaths a good
way to describe patient safety in hospitals: a
retrospective patient record review study.
September 16, 2015
Baines RJ, Langelaan M, de Bruijne M, et al. Is researching adverse events in hospital deaths a good way
to describe patient safety in hospitals: a re…
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psnet.ahrq.gov/node/849324/psn-pdf
May 24, 2023 - Learning from errors and resilience.
May 24, 2023
Arnal-Velasco D, Heras-Hernando V. Learning from errors and resilience. Curr Opin Anaesthesiol.
2023;36(3):376-381. doi:10.1097/aco.0000000000001257.
https://psnet.ahrq.gov/issue/learning-errors-and-resilience
The Safety II framework and organizational resilience b…
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psnet.ahrq.gov/node/34814/psn-pdf
January 01, 2015 - Prescribing for the elderly. Part I: Sensitivity of the elderly
to adverse drug reactions.
March 28, 2005
Nolan L, O'Malley K. Prescribing for the Elderly Part I: Sensitivity of the Elderly to Adverse Drug
Reactions*. J Am Geriatr Soc. 2015;36(2):142-149. doi:10.1111/j.1532-5415.1988.tb01785.x.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/47375/psn-pdf
November 02, 2018 - Ethical duty of health care systems to address interfacility
medical error discovery.
November 2, 2018
Antunez AG, Shuman AG, Jagsi R, et al. Ethical Duty of Health Care Systems to Address Interfacility
Medical Error Discovery. J Am Coll Surg. 2018;227(5):543-547. doi:10.1016/j.jamcollsurg.2018.08.184.
https://psn…
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psnet.ahrq.gov/node/46176/psn-pdf
October 04, 2017 - Incidence and severity of prescribing errors in parenteral
nutrition for pediatric inpatients at a neonatal and
pediatric intensive care unit.
October 4, 2017
Hermanspann T, Schoberer M, Robel-Tillig E, et al. Incidence and Severity of Prescribing Errors in
Parenteral Nutrition for Pediatric Inpatients at a Neonat…
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psnet.ahrq.gov/node/50922/psn-pdf
February 19, 2020 - An Organisation Losing its Memory? Patient Safety
Alerts: Implementation, Monitoring and Regulation in
England
February 19, 2020
Cousins D. Croydon, UK: Accidents against Medical Accidents; 2020.
https://psnet.ahrq.gov/issue/organisation-losing-its-memory-patient-safety-alerts-implementation-
monitoring-and-regul…
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psnet.ahrq.gov/node/60525/psn-pdf
May 27, 2020 - Public sector organizational failure: a study of collective
denial in the UK national health service.
May 27, 2020
Hendy J, Tucker DA. Public sector organizational failure: a study of collective denial in the UK national
health service. J Bus Ethics. 2020;2021;172:691–706. doi:10.1007/s10551-020-04517-1.
https://p…
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psnet.ahrq.gov/node/44705/psn-pdf
January 01, 2017 - Team dynamics, clinical work satisfaction, and patient
care coordination between primary care providers: a
mixed methods study.
December 7, 2016
Song H, Ryan M, Tendulkar S, et al. Team dynamics, clinical work satisfaction, and patient care
coordination between primary care providers: A mixed methods study. Health…
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psnet.ahrq.gov/node/844057/psn-pdf
February 08, 2023 - Impact of medical education on patient safety: finding the
signal through the noise.
February 8, 2023
Hwang J, Kelz RR. Impact of medical education on patient safety: finding the signal through the noise. BMJ
Qual Saf. 2023;32(2):61-64. doi:10.1136/bmjqs-2022-015054.
https://psnet.ahrq.gov/issue/impact-medical-edu…
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psnet.ahrq.gov/node/39621/psn-pdf
June 23, 2010 - Defining near misses: towards a sharpened definition
based on empirical data about error handling processes.
June 23, 2010
Kessels-Habraken M, Van der Schaaf T, De Jonge J, et al. Defining near misses: towards a sharpened
definition based on empirical data about error handling processes. Soc Sci Med. 2010;70(9):130…
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psnet.ahrq.gov/node/46669/psn-pdf
January 17, 2018 - Effect of therapeutic interchange on medication
reconciliation during hospitalization and upon discharge
in a geriatric population.
January 17, 2018
Wang JS, Fogerty RL, Horwitz LI. Effect of therapeutic interchange on medication reconciliation during
hospitalization and upon discharge in a geriatric population. P…
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psnet.ahrq.gov/node/837433/psn-pdf
June 15, 2022 - Unacceptable behaviours between healthcare workers:
just the tip of the patient safety iceberg.
June 15, 2022
Bamberger E, Bamberger P. Unacceptable behaviours between healthcare workers: just the tip of the
patient safety iceberg. BMJ Qual Saf. 2022;31(9):638-641. doi:10.1136/bmjqs-2021-014157.
https://psnet.ahrq…
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psnet.ahrq.gov/node/46933/psn-pdf
April 04, 2018 - Pain states, the opioid epidemic, and the role of
radiologists.
April 4, 2018
Jones MR, Kaye AD, Manchikanti L, et al. Pain States, the Opioid Epidemic, and the Role of Radiologists.
Curr Pain Headache Rep. 2018;22(3):20. doi:10.1007/s11916-018-0672-x.
https://psnet.ahrq.gov/issue/pain-states-opioid-epidemic-and-r…
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psnet.ahrq.gov/node/44869/psn-pdf
November 18, 2016 - Fake and expired medications in simulation-based
education: an underappreciated risk to patient safety.
November 18, 2016
Torrie J, Cumin D, Sheridan J, et al. Fake and expired medications in simulation-based education: an
underappreciated risk to patient safety. BMJ Qual Saf. 2016;25(12):917-920. doi:10.1136/bmjqs…