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psnet.ahrq.gov/node/46677/psn-pdf
June 25, 2018 - Diagnostic errors in paediatric cardiac intensive care.
June 25, 2018
Bhat PN, Costello JM, Aiyagari R, et al. Diagnostic errors in paediatric cardiac intensive care. Cardiol
Young. 2018;28(5):675-682. doi:10.1017/S1047951117002906.
https://psnet.ahrq.gov/issue/diagnostic-errors-paediatric-cardiac-intensive-care
R…
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psnet.ahrq.gov/node/33728/psn-pdf
May 01, 2012 - DC: Well, it is depressing that we see these three studies together, which suggests that there may not
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psnet.ahrq.gov/node/49861/psn-pdf
May 01, 2019 - the United States. (1-3) The
cost associated with caring for patients with PE is high; a 2013 study suggests
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psnet.ahrq.gov/curated-library/organizational-learning
August 11, 2025 - learning was more effective when closely aligned with the Organisational Learning in Hospitals model and suggests
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psnet.ahrq.gov/node/73678/psn-pdf
September 08, 2021 - A report of information technology and health
deficiencies in U.S. nursing homes.
September 8, 2021
Alexander GL, Madsen RW. A report of information technology and health deficiencies in U.S. nursing
homes. J Patient Saf. 2021;17(6):e483-e489. doi:10.1097/pts.0000000000000390.
https://psnet.ahrq.gov/issue/report-i…
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psnet.ahrq.gov/node/72865/psn-pdf
March 17, 2021 - 5 pandemic mistakes we keep repeating. We can learn
from our failures.
March 17, 2021
Zeynep Tufekci. The Atlantic. February 26, 2021
https://psnet.ahrq.gov/issue/5-pandemic-mistakes-we-keep-repeating-we-can-learn-our-failures
Failures in communication have impacts on patients, teams, organizations and society. Th…
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psnet.ahrq.gov/node/44445/psn-pdf
September 16, 2015 - Understanding nurses' and physicians' fear of
repercussions for reporting errors: clinician
characteristics, organization demographics, or leadership
factors?
September 16, 2015
Castel ES, Ginsburg LR, Zaheer S, et al. Understanding nurses' and physicians' fear of repercussions for
reporting errors: clinician cha…
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psnet.ahrq.gov/node/844551/psn-pdf
February 15, 2023 - Emotional safety is patient safety.
February 15, 2023
Lyndon A, Davis D-A, Sharma AE, et al. Emotional safety is patient safety. BMJ Qual Saf. 2023;32(7):369-
372. doi:10.1136/bmjqs-2022-015573.
https://psnet.ahrq.gov/issue/emotional-safety-patient-safety
Patient perspectives can provide unique insights into care …
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psnet.ahrq.gov/node/45496/psn-pdf
May 09, 2017 - The application of the Global Trigger Tool: a systematic
review.
May 9, 2017
Hibbert PD, Molloy CJ, Hooper TD, et al. The application of the Global Trigger Tool: a systematic review.
Int J Qual Health Care. 2016;28(6):640-649. doi:10.1093/intqhc/mzw115.
https://psnet.ahrq.gov/issue/application-global-trigger-tool-…
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psnet.ahrq.gov/node/43366/psn-pdf
March 04, 2015 - Safety of medication use in primary care.
March 4, 2015
Olaniyan JO, Ghaleb M, Dhillon S, et al. Safety of medication use in primary care. Int J Pharm Pract.
2015;23(1):3-20. doi:10.1111/ijpp.12120.
https://psnet.ahrq.gov/issue/safety-medication-use-primary-care
This systematic review found that incidence rates of…
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psnet.ahrq.gov/node/847060/psn-pdf
January 01, 2001 - The Emperor’s New Clothes: Or Whatever Happened To
“Human Error”?
January 1, 2001
Hollnagel E, Amalberti R. Chapter In: Dekker SWA, ed. Proceedings of the 4th International
Workshop on Human Error, Safety and Systems Development. Linköping Sweden: Linköping University;
2001.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/45372/psn-pdf
November 18, 2016 - Determinants of patient–oncologist prognostic
discordance in advanced cancer.
November 18, 2016
Gramling R, Fiscella K, Xing G, et al. Determinants of Patient-Oncologist Prognostic Discordance in
Advanced Cancer. JAMA Oncol. 2016;2(11):1421-1426. doi:10.1001/jamaoncol.2016.1861.
https://psnet.ahrq.gov/issue/determ…
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psnet.ahrq.gov/node/33927/psn-pdf
June 23, 2015 - Errors, incidents and accidents in anaesthetic practice.
June 23, 2015
Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study. Errors, incidents and
accidents in anaesthetic practice. Anaesth Intensive Care. 1993;21(5):506-19.
https://psnet.ahrq.gov/issue/errors-incidents-and-accidents-anae…
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psnet.ahrq.gov/node/46534/psn-pdf
January 31, 2018 - Safety considerations in learning new procedures: a
survey of surgeons.
January 31, 2018
Jaffe TA, Hasday SJ, Knol M, et al. Safety considerations in learning new procedures: a survey of
surgeons. J Surg Res. 2017;218:361-366. doi:10.1016/j.jss.2017.06.058.
https://psnet.ahrq.gov/issue/safety-considerations-learni…
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psnet.ahrq.gov/node/45633/psn-pdf
December 21, 2016 - Lost in translation: medication labeling for immigrant
families.
December 21, 2016
Smith MCJ, Yin S, Sanders LM. Lost in translation: Medication labeling for immigrant families. J Am Pharm
Assoc (2003). 2016;56(6):677-679. doi:10.1016/j.japh.2016.07.002.
https://psnet.ahrq.gov/issue/lost-translation-medication-lab…
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psnet.ahrq.gov/node/836761/psn-pdf
March 16, 2022 - Complexity bias in the prevention of iatrogenic injury:
why specific harms may inhibit performance.
March 16, 2022
Padula WV, Armstrong DG, Goldman DP. Complexity bias in the prevention of iatrogenic injury: why
specific harms may inhibit performance. Mayo Clin Proc. 2022;97(2):221-224.
doi:10.1016/j.mayocp.2021.1…
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psnet.ahrq.gov/node/866352/psn-pdf
July 24, 2024 - Patient falls in the operating room: why is this still a
problem in 2024?
July 24, 2024
Pellegrino A, Brook K. Patient falls in the operating room: why is this still a problem in 2024? J Patient Saf.
2024;20(6):e87-e90. doi:10.1097/pts.0000000000001248.
https://psnet.ahrq.gov/issue/patient-falls-operating-room-why…
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psnet.ahrq.gov/node/47081/psn-pdf
September 02, 2018 - Beyond Dr. Google: the evidence on consumer-facing
digital tools for diagnosis.
September 2, 2018
Millenson ML, Baldwin JL, Zipperer L, et al. Beyond Dr. Google: the evidence on consumer-facing digital
tools for diagnosis. Diagnosis (Berl). 2018;5(3):95-105. doi:10.1515/dx-2018-0009.
https://psnet.ahrq.gov/issue/b…
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psnet.ahrq.gov/node/44251/psn-pdf
January 13, 2016 - Early impact of the 2011 ACGME duty hour regulations on
surgical outcomes.
January 13, 2016
Scally CP, Ryan AM, Thumma JR, et al. Early impact of the 2011 ACGME duty hour regulations on surgical
outcomes. Surgery. 2015;158(6):1453-61. doi:10.1016/j.surg.2015.05.002.
https://psnet.ahrq.gov/issue/early-impact-2011-a…
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psnet.ahrq.gov/node/35749/psn-pdf
May 09, 2014 - Chemotherapy dose limits set by users of a computer
order entry system.
May 9, 2014
DuBeshter B; Griggs J; Angel C; Loughner J.
https://psnet.ahrq.gov/issue/chemotherapy-dose-limits-set-users-computer-order-entry-system
To avoid excessive dosing of chemotherapeutic agents, standardized dose limits must be agreed u…