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psnet.ahrq.gov/node/47527/psn-pdf
November 21, 2018 - Impact of interactions between drugs and laboratory test
results on diagnostic test interpretation—a systematic
review.
November 21, 2018
van Balveren JA, van de Venne WPHGV-, Erdem-Eraslan L, et al. Impact of interactions between drugs
and laboratory test results on diagnostic test interpretation - a systematic r…
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psnet.ahrq.gov/node/45430/psn-pdf
September 28, 2016 - Understanding and responding when things go wrong:
key principles for primary care educators.
September 28, 2016
McNab D, Bowie P, Ross A, et al. Understanding and responding when things go wrong: key principles for
primary care educators. Educ Prim Care. 2016;27(4):258-66. doi:10.1080/14739879.2016.1205959.
https…
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psnet.ahrq.gov/node/43001/psn-pdf
March 19, 2014 - Variability in the measurement of hospital-wide mortality
rates.
March 19, 2014
Shahian DM, Wolf RE, Iezzoni LI, et al. Variability in the measurement of hospital-wide mortality rates. N
Engl J Med. 2010;363(26):2530-9. doi:10.1056/NEJMsa1006396.
https://psnet.ahrq.gov/issue/variability-measurement-hospital-wide-m…
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psnet.ahrq.gov/node/47154/psn-pdf
May 23, 2018 - Comparison of military and civilian methods for
determining potentially preventable deaths: a systematic
review.
May 23, 2018
Janak JC, Sosnov JA, Bares JM, et al. Comparison of Military and Civilian Methods for Determining
Potentially Preventable Deaths: A Systematic Review. JAMA Surg. 2018;153(4):367-375.
doi:1…
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psnet.ahrq.gov/node/38887/psn-pdf
August 26, 2009 - Measuring patient safety culture: an assessment of the
clustering of responses at unit level and hospital level.
August 26, 2009
Smits M, Wagner C, Spreeuwenberg P, et al. Measuring patient safety culture: an assessment of the
clustering of responses at unit level and hospital level. Quality and Safety in Health Ca…
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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/35575/psn-pdf
April 11, 2011 - Parental preferences for error disclosure, reporting, and
legal action after medical error in the care of their
children.
April 11, 2011
Hobgood C, Tamayo-Sarver JH, Elms A, et al. Parental preferences for error disclosure, reporting, and
legal action after medical error in the care of their children. Pediatrics. …
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psnet.ahrq.gov/node/45816/psn-pdf
February 01, 2017 - Parent preferences for medical error disclosure: a
qualitative study.
February 1, 2017
Coffey M, Espin S, Hahmann T, et al. Parent Preferences for Medical Error Disclosure: A Qualitative Study.
Hosp Pediatr. 2017;7(1):24-30. doi:10.1542/hpeds.2016-0048.
https://psnet.ahrq.gov/issue/parent-preferences-medical-error…
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psnet.ahrq.gov/node/48172/psn-pdf
July 31, 2019 - Prevalence, severity, and nature of preventable patient
harm across medical care settings: systematic review and
meta-analysis.
July 31, 2019
Panagioti M, Khan K, Keers RN, et al. Prevalence, severity, and nature of preventable patient harm across
medical care settings: systematic review and meta-analysis. BMJ. 20…
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psnet.ahrq.gov/node/50863/psn-pdf
February 05, 2020 - Patient safety in inpatient mental health settings: a
systematic review.
February 5, 2020
Thibaut BI, Dewa LH, Ramtale SC, et al. Patient safety in inpatient mental health settings: a systematic
review. BMJ Open. 2019;9(12):e030230. doi:10.1136/bmjopen-2019-030230.
https://psnet.ahrq.gov/issue/patient-safety-inpat…
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psnet.ahrq.gov/node/73698/psn-pdf
September 15, 2021 - Effect of a mobile app on prehospital medication errors
during simulated pediatric resuscitation: a randomized
clinical trial.
September 15, 2021
Siebert JN, Bloudeau L, Combescure C, et al. Effect of a mobile app on prehospital medication errors
during simulated pediatric resuscitation: a randomized clinical tria…
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psnet.ahrq.gov/node/49460/psn-pdf
September 01, 2004 - and anonymous reporting, now considered an integral part of preventing medical errors, although with
varied
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psnet.ahrq.gov/node/867037/psn-pdf
January 01, 2025 - Medicine communication from hospital to residential aged
care facilities: a cross-sectional survey of aged care
facility staff.
October 30, 2024
Browning S, Raleigh RA, Hattingh HL. Medicine communication from hospital to residential aged care
facilities: a cross-sectional survey of aged care facility staff. Int J…
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psnet.ahrq.gov/node/867655/psn-pdf
February 26, 2025 - Learning Health Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
Despite an observable decrease in adverse events in health care over time, rat…
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psnet.ahrq.gov/node/41688/psn-pdf
April 17, 2013 - Teaching hospital financial status and patient outcomes
following ACGME duty hour reform.
April 17, 2013
Navathe AS, Silber JH, Small DS, et al. Teaching hospital financial status and patient outcomes following
ACGME duty hour reform. Health Serv Res. 2013;48(2 Pt 1):476-98. doi:10.1111/j.1475-
6773.2012.01453.x.
…
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psnet.ahrq.gov/node/46190/psn-pdf
August 17, 2017 - Preventing harm in the ICU—building a culture of safety
and engaging patients and families.
August 17, 2017
Thornton KC, Schwarz JJ, Gross K, et al. Preventing Harm in the ICU-Building a Culture of Safety and
Engaging Patients and Families. Crit Care Med. 2017;45(9):1531-1537.
doi:10.1097/CCM.0000000000002556.
ht…
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psnet.ahrq.gov/node/37674/psn-pdf
June 16, 2011 - An overview of patient safety climate in the VA.
June 16, 2011
Hartmann CW, Rosen AK, Meterko M, et al. An overview of patient safety climate in the VA. Health Serv
Res. 2008;43(4):1263-84. doi:10.1111/j.1475-6773.2008.00839.x.
https://psnet.ahrq.gov/issue/overview-patient-safety-climate-va
Measurement of institut…
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psnet.ahrq.gov/node/44430/psn-pdf
October 28, 2015 - The role of dynamic trade-offs in creating safety—a
qualitative study of handover across care boundaries in
emergency care.
October 28, 2015
Sujan M, Spurgeon P, Cooke M. The role of dynamic trade-offs in creating safety—A qualitative study of
handover across care boundaries in emergency care. Reliab Eng Syst Saf.…
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psnet.ahrq.gov/node/41643/psn-pdf
September 05, 2012 - A Randomized Field Study of a Leadership WalkRounds-
Based Intervention.
September 5, 2012
Tucker AL, Singer SJ. Cambridge, MA: Harvard Business School; June 25, 2012. HBS Working Paper No.
12-113.
https://psnet.ahrq.gov/issue/randomized-field-study-leadership-walkrounds-based-intervention
Leadership WalkRounds h…
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psnet.ahrq.gov/node/44350/psn-pdf
July 29, 2015 - Reporting and using near-miss events to improve patient
safety in diverse primary care practices: a collaborative
approach to learning from our mistakes.
July 29, 2015
Crane S, Sloane PD, Elder NC, et al. Reporting and Using Near-miss Events to Improve Patient Safety in
Diverse Primary Care Practices: A Collaborat…