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psnet.ahrq.gov/node/39863/psn-pdf
January 04, 2011 - Improving the quality of drug error reporting.
January 4, 2011
Armitage G, Newell R, Wright J. Improving the quality of drug error reporting. J Eval Clin Pract.
2010;16(6):1189-97. doi:10.1111/j.1365-2753.2009.01293.x.
https://psnet.ahrq.gov/issue/improving-quality-drug-error-reporting
This analysis of voluntarily…
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psnet.ahrq.gov/node/35133/psn-pdf
March 11, 2011 - Parents as partners in obtaining the medication history.
March 11, 2011
Porter SC, Kohane IS, Goldmann DA. Parents as partners in obtaining the medication history. J Am Med
Inform Assoc. 2005;12(3):299-305.
https://psnet.ahrq.gov/issue/parents-partners-obtaining-medication-history
This study examined the utility o…
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psnet.ahrq.gov/node/36183/psn-pdf
March 28, 2011 - A cross-cultural survey of residents' perceived barriers in
questioning/challenging authority.
March 28, 2011
Kobayashi H, Pian-Smith M, Sato M, et al. A cross-cultural survey of residents' perceived barriers in
questioning/challenging authority. Qual Saf Health Care. 2006;15(4):277-83.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/36610/psn-pdf
January 14, 2011 - Prevent medication errors: a New Year's resolution:
teaching patients about their medications.
January 14, 2011
Polzien G. Prevent medication errors: A New Year's resolution: teaching patients about their medications.
Home Healthc Nurse. 2007;25(1):59-62.
https://psnet.ahrq.gov/issue/prevent-medication-errors-new-…
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psnet.ahrq.gov/node/45558/psn-pdf
May 10, 2017 - Prevention Is Better Than Cure: Learning From Adverse
Events in Healthcare.
May 10, 2017
Leistikow I. Boca Raton, FL: CRC Press; 2017. ISBN: 9781138197763.
https://psnet.ahrq.gov/issue/prevention-better-cure-learning-adverse-events-healthcare
Patients continue to experience preventable health care–associated harm.…
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psnet.ahrq.gov/node/40185/psn-pdf
December 29, 2014 - Variation in the rates of adverse events between hospitals
and hospital departments.
December 29, 2014
Zegers M, de Bruijne M, Spreeuwenberg P, et al. Variation in the rates of adverse events between
hospitals and hospital departments. Int J Qual Health Care. 2011;23(2):126-33.
doi:10.1093/intqhc/mzq086.
https://…
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psnet.ahrq.gov/node/47511/psn-pdf
October 24, 2018 - Wiser Healthcare.
October 24, 2018
Australian National Health and Medical Research Council.
https://psnet.ahrq.gov/issue/wiser-healthcare
Overdiagnosis and the subsequent overuse of medical care contributes to unnecessary financial,
psychological, and physical risk to patients. This research collaborative draws fr…
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psnet.ahrq.gov/node/47469/psn-pdf
October 17, 2018 - Making doctors better.
October 17, 2018
Gerada C, Chatfield C, Rimmer A, et al. Making doctors better. BMJ. 2018;363:k4147.
doi:10.1136/bmj.k4147.
https://psnet.ahrq.gov/issue/making-doctors-better
Systems must be designed to support staff well-being and safety. This commentary introduces an ongoing
collection of…
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psnet.ahrq.gov/node/34751/psn-pdf
March 07, 2005 - Merry and McCall Smith's Errors, Medicine, and the Law.
2nd ed.
March 7, 2005
Merry A, Brookbanks W. Cambridge, UK: Cambridge University Press; 2017. ISBN: 9781107180499
https://psnet.ahrq.gov/issue/errors-medicine-and-law
Merry, a New Zealand anesthesiologist, and Smith, a legal educator and a popular writer, exp…
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psnet.ahrq.gov/node/45027/psn-pdf
April 06, 2016 - Patient Safety 2030.
April 6, 2016
Yu A, Flott K, Chainani N, Fontana G, Darzi A. London, UK: NIHR Imperial Patient Safety Translational
Research Centre; 2016.
https://psnet.ahrq.gov/issue/patient-safety-2030
Examining emerging trends in patient safety improvement work, this report recommends strategies and
tools…
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psnet.ahrq.gov/node/35414/psn-pdf
May 21, 2014 - Assessment of the National Patient Safety Initiative:
Context and Baseline Evaluation Report 1.
May 21, 2014
Santa Monica, CA: RAND Corporation; 2005. ISBN 0833037870.
https://psnet.ahrq.gov/issue/assessment-national-patient-safety-initiative-context-and-baseline-evaluation-
report-1
The authors report on the his…
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psnet.ahrq.gov/node/34823/psn-pdf
April 06, 2011 - Use of medical emergency team (MET) responses to
detect medical errors.
April 6, 2011
Braithwaite RS, Devita MA, Mahidhara R, et al. Use of medical emergency team (MET) responses to detect
medical errors. Qual Saf Health Care. 2004;13(4):255-259.
https://psnet.ahrq.gov/issue/use-medical-emergency-team-met-response…
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psnet.ahrq.gov/node/40284/psn-pdf
March 09, 2011 - Speaking Up Constructively: Managerial Practices that
Elicit Solutions from Front-Line Employees.
March 9, 2011
Adler-Milstein JR, Singer SJ, Toffel MW. Cambridge, MA: Harvard Business School; August 25, 2010. HBS
Working Paper No. 11-005.
https://psnet.ahrq.gov/issue/speaking-constructively-managerial-practices-e…
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psnet.ahrq.gov/node/40455/psn-pdf
June 20, 2011 - Minimizing electronic health record patient–note
mismatches.
June 20, 2011
Wilcox AB, Chen Y-H, Hripcsak G. Minimizing electronic health record patient-note mismatches. J Am Med
Inform Assoc. 2011;18(4):511-4. doi:10.1136/amiajnl-2010-000068.
https://psnet.ahrq.gov/issue/minimizing-electronic-health-record-patient…
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psnet.ahrq.gov/node/40067/psn-pdf
December 08, 2010 - Slowing down to stay out of trouble in the operating
room: remaining attentive in automaticity.
December 8, 2010
Moulton C-A, Regehr G, Lingard LA, et al. Slowing down to stay out of trouble in the operating room:
remaining attentive in automaticity. Acad Med. 2010;85(10):1571-7. doi:10.1097/ACM.0b013e3181f073dd.
…
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psnet.ahrq.gov/node/45847/psn-pdf
February 15, 2017 - Is there a 'weekend effect' in major trauma?
February 15, 2017
Metcalfe D, Perry DC, Bouamra O, et al. Is there a 'weekend effect' in major trauma? Emerg Med J.
2016;33(12):836-842. doi:10.1136/emermed-2016-206049.
https://psnet.ahrq.gov/issue/there-weekend-effect-major-trauma
The weekend effect has been observed …
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psnet.ahrq.gov/node/40297/psn-pdf
March 16, 2011 - Roundtable on public policy affecting patient safety.
March 16, 2011
Crane RM, Raymond B. Roundtable on Public Policy Affecting Patient Safety. J Patient Saf. 2011;7(1):5-
10. doi:10.1097/pts.0b013e31820c98cd.
https://psnet.ahrq.gov/issue/roundtable-public-policy-affecting-patient-safety
This publication summarize…
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psnet.ahrq.gov/node/38750/psn-pdf
July 01, 2009 - Probability error in diagnosis: the conjunction fallacy
among beginning medical students.
July 1, 2009
Rao G. Probability error in diagnosis: the conjunction fallacy among beginning medical students. Fam Med.
2009;41(4):262-5.
https://psnet.ahrq.gov/issue/probability-error-diagnosis-conjunction-fallacy-among-begin…
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psnet.ahrq.gov/node/47309/psn-pdf
August 22, 2018 - Defining patient safety events in inpatient psychiatry.
August 22, 2018
Marcus SC, Hermann R, Cullen SW. Defining Patient Safety Events in Inpatient Psychiatry. J Patient Saf.
2018;17(8):e1452-e1457. doi:10.1097/PTS.0000000000000520.
https://psnet.ahrq.gov/issue/defining-patient-safety-events-inpatient-psychiatry
…
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psnet.ahrq.gov/node/37564/psn-pdf
June 12, 2008 - The medical emergency team system: a two hospital
comparison.
June 12, 2008
Young L, Donald M, Parr M, et al. The Medical Emergency Team system: a two hospital comparison.
Resuscitation. 2008;77(2):180-8. doi:10.1016/j.resuscitation.2007.11.016.
https://psnet.ahrq.gov/issue/medical-emergency-team-system-two-hospit…