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psnet.ahrq.gov/node/38809/psn-pdf
November 14, 2011 - Safety First: Top of Your Board's Agenda: 100 Day
Challenge Survey Report.
November 14, 2011
The Patients Association. Harrow, Middlesex, UK: The Patients Association; June 2009.
https://psnet.ahrq.gov/issue/safety-first-top-your-boards-agenda-100-day-challenge-survey-report
This publication summarizes the results…
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psnet.ahrq.gov/node/43107/psn-pdf
March 14, 2016 - Researchers' roles in patient safety improvement.
March 14, 2016
Pietikäinen E, Reiman T, Heikkilä J, et al. Researchers' Roles in Patient Safety Improvement. J Patient Saf.
2016;12(1):25-33. doi:10.1097/PTS.0000000000000096.
https://psnet.ahrq.gov/issue/researchers-roles-patient-safety-improvement
Through a self-…
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psnet.ahrq.gov/node/35917/psn-pdf
July 23, 2010 - Audibility of patient clinical alarms to hospital nursing
personnel.
July 23, 2010
Sobieraj J, Ortega C, West I, et al. Audibility of patient clinical alarms to hospital nursing personnel. Mil
Med. 2006;171(4):306-10.
https://psnet.ahrq.gov/issue/audibility-patient-clinical-alarms-hospital-nursing-personnel
The i…
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psnet.ahrq.gov/node/866569/psn-pdf
September 01, 2024 - Guidelines in Practice.
September 1, 2024
Guidelines in Practice. AORN J. 2020-2024.
https://psnet.ahrq.gov/issue/guidelines-practice
Awareness and consistent application of professional guidance can support safe, effective care delivery.
This collection of articles presents short introductions to a range of guide…
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psnet.ahrq.gov/node/36056/psn-pdf
September 27, 2010 - Path to safety: benefits of the 2005 Patient Safety and
Quality Improvement Act.
September 27, 2010
McBride D, Greening A, Redmond D. Path to safety: benefits of the 2005 Patient Safety and Quality
Improvement Act. Healthc Financ Manage. 2006;60(6):84-8.
https://psnet.ahrq.gov/issue/path-safety-benefits-2005-patie…
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psnet.ahrq.gov/node/39805/psn-pdf
September 01, 2010 - More to teamwork than knowledge, skill and attitude.
September 1, 2010
Siassakos D, Draycott TJ, Crofts JF, et al. More to teamwork than knowledge, skill and attitude. BJOG.
2010;117(10):1262-9. doi:10.1111/j.1471-0528.2010.02654.x.
https://psnet.ahrq.gov/issue/more-teamwork-knowledge-skill-and-attitude
This study…
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psnet.ahrq.gov/node/37218/psn-pdf
March 04, 2011 - Medicaid markets and pediatric patient safety in
hospitals.
March 4, 2011
Smith RB, Cheung R, Owens P, et al. Medicaid markets and pediatric patient safety in hospitals. Health
Serv Res. 2007;42(5):1981-98.
https://psnet.ahrq.gov/issue/medicaid-markets-and-pediatric-patient-safety-hospitals
This study examined th…
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psnet.ahrq.gov/node/36914/psn-pdf
March 21, 2017 - Reasons for after-hours calls by hospital floor nurses to
on-call physicians.
March 21, 2017
Bernstam E, Pancheri KK, Johnson CM, et al. Reasons for after-hours calls by hospital floor nurses to on-
call physicians. Jt Comm J Qual Patient Saf. 2007;33(6):342-9.
https://psnet.ahrq.gov/issue/reasons-after-hours-call…
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psnet.ahrq.gov/node/38557/psn-pdf
April 22, 2009 - Antecedents of severe and nonsevere medication errors.
April 22, 2009
Chang Y-K, Mark BA. Antecedents of severe and nonsevere medication errors. J Nurs Scholarsh.
2009;41(1):70-8. doi:10.1111/j.1547-5069.2009.01253.x.
https://psnet.ahrq.gov/issue/antecedents-severe-and-nonsevere-medication-errors
This study examin…
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psnet.ahrq.gov/node/50777/psn-pdf
January 08, 2020 - Safety culture across cultures.
January 8, 2020
Yorio PL, Edwards J, Hoeneveld D. Safety culture across cultures. Safety Sci. 2019;120:402-410.
doi:10.1016/j.ssci.2019.07.021.
https://psnet.ahrq.gov/issue/safety-culture-across-cultures
This paper discusses the relationship between national culture and safety cultu…
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psnet.ahrq.gov/node/39431/psn-pdf
April 07, 2010 - Identified safety risks with splitting and crushing oral
medications.
April 7, 2010
Paparella S. Identified safety risks with splitting and crushing oral medications. Journal of emergency
nursing: JEN : official publication of the Emergency Department Nurses Association. 2010;36(2):156-8.
doi:10.1016/j.jen.2009.11…
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psnet.ahrq.gov/node/36301/psn-pdf
October 26, 2010 - The culture of a trauma team in relation to human factors.
October 26, 2010
Cole E, Crichton N. The culture of a trauma team in relation to human factors. J Clin Nurs. 2006;15(10).
doi:10.1111/j.1365-2702.2006.01566.x.
https://psnet.ahrq.gov/issue/culture-trauma-team-relation-human-factors
The investigators observ…
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psnet.ahrq.gov/node/34791/psn-pdf
March 28, 2005 - Drug-related hospital admissions.
March 28, 2005
Einarson TR
https://psnet.ahrq.gov/issue/drug-related-hospital-admissions
This systematic review summarizes reported rates of drug-related hospital admissions from 36 different
studies. The findings suggest that approximately 5% of all admissions are attributable to…
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psnet.ahrq.gov/node/36860/psn-pdf
January 20, 2016 - IHI Global Trigger Tool for Measuring Adverse Events.
2nd Edition.
January 20, 2016
Griffin FA, Resar RK. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare
Improvement; 2009.
https://psnet.ahrq.gov/issue/ihi-global-trigger-tool-measuring-adverse-events-2nd-edition
This white paper describ…
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psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
January 01, 2024 - Sterile water and sterile saline are used commonly but are expensive; evidence suggests tap water irrigation … Common sense suggests that, if the number of foreign bodies on imaging were to match the number of objects
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psnet.ahrq.gov/node/45495/psn-pdf
January 01, 2021 - Medical students raising concerns.
October 12, 2016
Druce MR, Hickey A, Warrens AN, et al. Medical Students Raising Concerns. J Patient Saf.
2021;17(5):e367-e372.
https://psnet.ahrq.gov/issue/medical-students-raising-concerns
A key aspect of safety culture is that all team members feel comfortable with raising saf…
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psnet.ahrq.gov/node/34696/psn-pdf
June 23, 2015 - A piece of my mind. Coping with fallibility.
June 23, 2015
Levinson W, Dunn PM. A piece of my mind. Coping with fallibility. JAMA. 1989;261(15):2252.
https://psnet.ahrq.gov/issue/piece-my-mind-coping-fallibility
The authors relate personal experiences with physician error, including the professional and emotional
…
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psnet.ahrq.gov/node/36708/psn-pdf
April 21, 2011 - Missed breast cancers at US-guided core needle biopsy:
how to reduce them.
April 21, 2011
Youk JH, Kim E-K, Kim MJ, et al. Missed breast cancers at US-guided core needle biopsy: how to reduce
them. Radiographics. 2007;27(1):79-94.
https://psnet.ahrq.gov/issue/missed-breast-cancers-us-guided-core-needle-biopsy-how-…
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psnet.ahrq.gov/node/47915/psn-pdf
April 03, 2019 - Adversarial attacks on medical machine learning.
April 3, 2019
Finlayson SG, Bowers JD, Ito J, et al. Adversarial attacks on medical machine learning. Science (1979).
2019;363(6433):1287-1289. doi:10.1126/science.aaw4399.
https://psnet.ahrq.gov/issue/adversarial-attacks-medical-machine-learning
This review article…
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psnet.ahrq.gov/node/34898/psn-pdf
April 21, 2011 - Crossing to safety: transforming healthcare organizations
for patient safety.
April 21, 2011
Ralston JD, Larson EB. Crossing to safety: transforming healthcare organizations for patient safety. J
Postgrad Med. 2005;51(1):61-67.
https://psnet.ahrq.gov/issue/crossing-safety-transforming-healthcare-organizations-pati…