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psnet.ahrq.gov/node/44157/psn-pdf
November 06, 2015 - Are measurements of patient safety culture and adverse
events valid and reliable? Results from a cross sectional
study.
November 6, 2015
Farup PG. Are measurements of patient safety culture and adverse events valid and reliable? Results from
a cross sectional study. BMC Health Serv Res. 2015;15:186. doi:10.1186/s1…
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psnet.ahrq.gov/node/47255/psn-pdf
August 29, 2018 - Influence of shift duration on cognitive performance of
emergency physicians: a prospective cross-sectional
study.
August 29, 2018
Persico N, Maltese F, Ferrigno C, et al. Influence of Shift Duration on Cognitive Performance of Emergency
Physicians: A Prospective Cross-Sectional Study. Ann Emerg Med. 2018;72(2):17…
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psnet.ahrq.gov/node/47325/psn-pdf
January 01, 2020 - What can apologies in the electronic health record tell us
about health care quality, processes, and safety?
August 29, 2018
Matulis JC, North F. What Can Apologies in the Electronic Health Record Tell Us About Health Care
Quality, Processes, and Safety? J Patient Saf. 2020;16(3):e187-e193. doi:10.1097/pts.00000000…
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psnet.ahrq.gov/node/45451/psn-pdf
October 05, 2016 - Healthcare professional and patient codesign and
validation of a mechanism for service users to feedback
patient safety experiences following a care transfer: a
qualitative study.
October 5, 2016
Scott J, Heavey E, Waring J, et al. Healthcare professional and patient codesign and validation of a
mechanism for ser…
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psnet.ahrq.gov/node/35926/psn-pdf
July 26, 2010 - The patient's right to safety—improving the quality of care
through litigation against hospitals.
July 26, 2010
Annas GJ. The patient's right to safety--improving the quality of care through litigation against hospitals. N
Engl J Med. 2006;354(19):2063-2066.
https://psnet.ahrq.gov/issue/patients-right-safety-impro…
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psnet.ahrq.gov/node/43853/psn-pdf
March 11, 2015 - Expressing concern and writing it down: an experimental
study investigating transfer of information at nursing
handover.
March 11, 2015
Lee H, Cumin D, Devcich DA, et al. Expressing concern and writing it down: an experimental study
investigating transfer of information at nursing handover. J Adv Nurs. 2015;71(1):…
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psnet.ahrq.gov/node/43499/psn-pdf
September 03, 2014 - Older folks in hospitals: the contributing factors and
recommendations for incident prevention.
September 3, 2014
Mansah M, Griffiths R, Fernandez R, et al. Older folks in hospitals: the contributing factors and
recommendations for incident prevention. J Patient Saf. 2014;10(3):146-53.
doi:10.1097/PTS.0b013e318299…
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psnet.ahrq.gov/node/45214/psn-pdf
July 13, 2016 - Recognizing quality improvement and patient safety
activities in academic promotion in departments of
medicine: innovative language in promotion criteria.
July 13, 2016
Staiger TO, Mills LM, Wong BM, et al. Recognizing Quality Improvement and Patient Safety Activities in
Academic Promotion in Departments of Medici…
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psnet.ahrq.gov/node/862150/psn-pdf
February 07, 2024 - Effectiveness of ChatGPT in clinical pharmacy and the
role of artificial intelligence in medication therapy
management.
February 7, 2024
Roosan D, Padua P, Khan R, et al. Effectiveness of ChatGPT in clinical pharmacy and the role of artificial
intelligence in medication therapy management. J Am Pharm Assoc (2003).…
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psnet.ahrq.gov/node/38662/psn-pdf
April 12, 2011 - Patient error: a preliminary taxonomy.
April 12, 2011
Buetow S, Kiata L, Liew T, et al. Patient error: a preliminary taxonomy. Ann Fam Med. 2009;7(3):223-31.
doi:10.1370/afm.941.
https://psnet.ahrq.gov/issue/patient-error-preliminary-taxonomy
Preliminary research has found that patient factors may contribute to er…
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psnet.ahrq.gov/node/36834/psn-pdf
August 26, 2011 - Healthcare climate: a framework for measuring and
improving patient safety.
August 26, 2011
Zohar D, Livne Y, Tenne-Gazit O, et al. Healthcare climate: a framework for measuring and improving
patient safety. Crit Care Med. 2007;35(5):1312-7.
https://psnet.ahrq.gov/issue/healthcare-climate-framework-measuring-and-i…
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psnet.ahrq.gov/node/35134/psn-pdf
June 22, 2009 - Introduction of the medical emergency team (MET)
system: a cluster-randomised controlled trial.
June 22, 2009
Hillman K, Chen J, Cretikos M, et al. Introduction of the medical emergency team (MET) system: a cluster-
randomised controlled trial. Lancet. 2005;365(9477):2091-7.
https://psnet.ahrq.gov/issue/introducti…
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psnet.ahrq.gov/node/74184/psn-pdf
May 05, 2017 - Systematic review of the impact of physician implicit
racial bias on clinical decision making.
May 5, 2017
Dehon E, Weiss N, Jones J, et al. Systematic review of the impact of physician implicit racial bias on
clinical decision making. Acad Emerg Med. 2017;24(8):895-904. doi:10.1111/acem.13214.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/867382/psn-pdf
December 18, 2024 - Pharmacists’ perceptions of error reporting systems.
December 18, 2024
Hartt CM, Weigand H, MacDonald AJ, et al. Pharmacists’ perceptions of error reporting systems. J Patient
Saf Risk Manag. 2024;29(6):268-273. doi:10.1177/25160435241288287.
https://psnet.ahrq.gov/issue/pharmacists-perceptions-error-reporting-syst…
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psnet.ahrq.gov/node/45250/psn-pdf
July 27, 2016 - Risk factors for i.v. compounding errors when using an
automated workflow management system.
July 27, 2016
Deng Y, Lin AC, Hingl J, et al. Risk factors for i.v. compounding errors when using an automated workflow
management system. Am J Health Syst Pharm. 2016;73(12):887-893. doi:10.2146/ajhp150278.
https://psnet.…
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psnet.ahrq.gov/node/50746/psn-pdf
December 18, 2019 - The influence of organizational culture, climate and
commitment on speaking up about medical errors.
December 18, 2019
Levine KJ, Carmody M, Silk KJ. The influence of organizational culture, climate and commitment on
speaking up about medical errors. J Nurs Manag. 2019;28(1):130-138. doi:10.1111/jonm.12906.
https:…
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psnet.ahrq.gov/node/73630/psn-pdf
August 25, 2021 - Towards safer healthcare: qualitative insights from a
process view of organisational learning from failure.
August 25, 2021
Monazam Tabrizi N, Masri F. Towards safer healthcare: qualitative insights from a process view of
organisational learning from failure. BMJ Open. 2021;11(8):e048036. doi:10.1136/bmjopen-2020-0…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
May 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Fatal Error in Neonate: Does ‘Just Culture’ Provide an Answer?
*
*
Source and Credits
This presentation is based on the May 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Sidney W.A. Dekker, Ph…
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December 15, 2024 - Breadcrumb
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September 15, 2024 - Missed Nursing Care
Citation Text:
Missed Nursing Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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