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psnet.ahrq.gov/issue/relationships-between-comprehensive-characteristics-nurse-work-schedules-and-adverse-patient
October 06, 2010 - Review
Relationships between comprehensive characteristics of nurse work schedules and adverse patient outcomes: a systematic literature review.
Citation Text:
Bae S‐H. Relationships between comprehensive characteristics of nurse work schedules and adverse patient outcomes: a systematic …
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psnet.ahrq.gov/issue/factors-associated-intern-fatigue
October 28, 2009 - Study
Factors associated with intern fatigue.
Citation Text:
Friesen LD, Vidyarthi A, Baron RB, et al. Factors associated with intern fatigue. J Gen Intern Med. 2008;23(12):1981-6. doi:10.1007/s11606-008-0798-3.
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psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
March 30, 2022 - heart failure is discharged on furosemide (a diuretic) with a follow-up visit with a cardiologist in 4 weeks
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psnet.ahrq.gov/issue/monitoring-patient-safety-primary-care-exploratory-study-using-depth-semistructured
December 14, 2016 - Study
Monitoring patient safety in primary care: an exploratory study using in-depth semistructured interviews.
Citation Text:
Samra R, Bottle A, Aylin PP. Monitoring patient safety in primary care: an exploratory study using in-depth semistructured interviews. BMJ Open. 2015;5(9):e00812…
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psnet.ahrq.gov/issue/when-policy-meets-physiology-challenge-reducing-resident-work-hours
January 10, 2017 - Study
When policy meets physiology: the challenge of reducing resident work hours.
Citation Text:
Lockley SW, Landrigan CP, Barger LK, et al. When policy meets physiology: the challenge of reducing resident work hours. Clin Orthop Relat Res. 2006;449:116-127.
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psnet.ahrq.gov/node/39524/psn-pdf
January 17, 2012 - Computerized medication order errors studied.
January 17, 2012
McGee MK. Information Week. April 28, 2010.
https://psnet.ahrq.gov/issue/computerized-medication-order-errors-studied
This news article details how research on errors related to computerized provider order entry may help
prevent them in the future.
ht…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.443_slideshow.ppt
May 01, 2018 - : Ambulatory Test Result Management
Ambulatory encounters are episodic
Test results arrive days to weeks
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psnet.ahrq.gov/node/60997/psn-pdf
October 07, 2020 - ‘You’re going to release him when he was hurting
himself?’
October 7, 2020
Dahlberg B. Kaiser Health News. September 29, 2020.
https://psnet.ahrq.gov/issue/youre-going-release-him-when-he-was-hurting-himself
This story discusses failures related emergency psychiatric assessment, including premature discharge,
imp…
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psnet.ahrq.gov/node/60163/psn-pdf
March 25, 2020 - Broken, fragmented health-care system failed daughter
who died by suicide.
March 25, 2020
Klowak M. CBC News. March 9, 2020.
https://psnet.ahrq.gov/issue/broken-fragmented-health-care-system-failed-daughter-who-died-suicide
System weaknesses are often at the root of never events. This news story discusses the suic…
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psnet.ahrq.gov/node/39410/psn-pdf
March 31, 2010 - Doctors fear work caps for residents may be bad
medicine.
March 31, 2010
Shapira I.
https://psnet.ahrq.gov/issue/doctors-fear-work-caps-residents-may-be-bad-medicine
This news piece examines the work week of resident physicians and discusses how further limiting
trainees' work hours might reduce their experientia…
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psnet.ahrq.gov/issue/dying-weekend-retrospective-cohort-study-association-between-day-hospital-presentation-and
April 18, 2012 - Study
Dying for the weekend: a retrospective cohort study on the association between day of hospital presentation and the quality and safety of stroke care.
Citation Text:
Palmer WL, Bottle A, Davie C, et al. Dying for the weekend: a retrospective cohort study on the association betwee…
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psnet.ahrq.gov/issue/investigating-adverse-event-free-admissions-medicare-inpatients-patient-safety-indicator
May 04, 2016 - Study
Investigating adverse event free admissions in Medicare inpatients as a patient safety indicator.
Citation Text:
King A, Bottle A, Faiz O, et al. Investigating Adverse Event Free Admissions in Medicare Inpatients as a Patient Safety Indicator. Ann Surg. 2017;265(5):910-915. doi:10.…
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psnet.ahrq.gov/node/34864/psn-pdf
April 24, 2018 - ISMP Medication Safety Alert® Acute Care Edition.
April 24, 2018
Plymouth Meeting, PA; Institute for Safe Medication Practices. ISSN 1550-6312.
https://psnet.ahrq.gov/issue/ismp-medication-safety-alertr-acute-care-edition
The Institute for Safe Medication Practices' (ISMP) signature bi-weekly newsletter recounts ac…
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psnet.ahrq.gov/node/43071/psn-pdf
March 26, 2014 - Can wearable tech prevent healthcare errors?
March 26, 2014
Reese SM. Information Week. March 11, 2014.
https://psnet.ahrq.gov/issue/can-wearable-tech-prevent-healthcare-errors
This article describes how wearable technologies for clinicians can improve workload distribution,
information gathering, and staffi…
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psnet.ahrq.gov/node/34629/psn-pdf
March 05, 2008 - AHRQ's News Now.
March 5, 2008
Rockville, MD: Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/ahrqs-patient-safety-e-newsletter
E-newsletter issued weekly to make important patient safety news and information available. The E-
newsletter features concise descriptions of findings from …
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psnet.ahrq.gov/node/42240/psn-pdf
May 01, 2013 - After the Error: Speaking Out About Patient Safety to
Save Lives.
May 1, 2013
McIver SB, Wyndham R. Toronto, Canada: ECW Press; 2013. ISBN: 9781770411104.
https://psnet.ahrq.gov/issue/after-error-speaking-out-about-patient-safety-save-lives
This book includes stories of medical errors in Canada, shares patient and…
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psnet.ahrq.gov/node/36344/psn-pdf
February 17, 2011 - Clinical problem-solving. Lost in transcription.
February 17, 2011
Kalus RM, Shojania KG, Amory JK, et al. Clinical problem-solving. Lost in transcription. N Engl J Med.
2006;355(14):1487-91.
https://psnet.ahrq.gov/issue/clinical-problem-solving-lost-transcription
This case involves an iatrogenic reaction that occ…
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psnet.ahrq.gov/issue/san-diego-center-patient-safety
March 09, 2025 - Multi-use Website
San Diego Center for Patient Safety.
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March 17, 2011
The San Diego Center for Patient Safety (SDCPS) consists o…
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psnet.ahrq.gov/node/42493/psn-pdf
August 14, 2013 - Partnering to prevent falls: using a multimodal
multidisciplinary team.
August 14, 2013
Volz TM, Swaim J. Partnering to prevent falls: using a multimodal multidisciplinary team. J Nurs Adm.
2013;43(6):336-41. doi:10.1097/NNA.0b013e3182942c5a.
https://psnet.ahrq.gov/issue/partnering-prevent-falls-using-multimodal-m…
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psnet.ahrq.gov/node/39379/psn-pdf
March 17, 2010 - Characteristics of Weekday and Weekend Hospital
Admissions, 2007.
March 17, 2010
Ryan K, Levit K, Davis PH. HCUP Statistical Brief #87. Rockville, MD: Agency for Healthcare Research and
Quality; March 2010.
https://psnet.ahrq.gov/issue/characteristics-weekday-and-weekend-hospital-admissions-2007
Using data from t…