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Sakai K, Takatsu A, Shigeta A, et al. Int J Qual Health Care. 2010;22:9-15.
Sakai K ; Takatsu A ; Shigeta A; et al. Potential medical adverse events associated with death: a forensic pathology perspective. Int J Qual Health Care. 2010; 22: 15-Sep
Nearly 9% of autopsies in this Japanese study revealed a potentially preventable adverse event, most commonly a diagnostic error.
Trauma resuscitation errors and computer-assisted decision support.
Fitzgerald M, Cameron P, Mackenzie C, et al. Arch Surg. 2011;146:218-225.
Comparison of the clinical diagnosis and subsequent autopsy findings in medical malpractice.
Pakis I, Polat O, Yayci N, Karapirli M. Am J Forensic Med Pathol. 2010;31:218-221.
Error tracking in a clinical biochemistry laboratory.
Szecsi PB, Ødum L. Clin Chem Lab Med. 2009;47:1253-1257.
Decimal numbers and safe interpretation of clinical pathology results.
Sinnott M, Eley R, Steinle V, Boyde M, Trenning L, Dimeski G. J Clin Pathol. 2014;67:179-181.
In Conversation with…Albert Wu, MD, MPH
Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis.
Muething SE, Conway PH, Kloppenborg E, et al. Qual Saf Health Care. 2010;19:435-439.
The hazards of diagnosis.
Schattner A, Magazanik N, Haran M. QJM. 2010;103:583-587.
Medical errors and consequent adverse events in critically ill surgical patients in a tertiary care teaching hospital in Delhi.
Kumar S, Chaudhary S. J Emerg Trauma Shock. 2009;2:80-84.
Early readmissions to the department of medicine as a screening tool for monitoring quality of care problems.
Balla U, Malnick S, Schattner A. Medicine (Baltimore). 2008;87:294-300.
Adverse events in long-term care residents transitioning from hospital back to nursing home.
Kapoor A, Field T, Handler S, et al. JAMA Intern Med. 2019 Jul 22; [Epub ahead of print].
High-alert medication stratification tool-revised: an exploratory study of an objective, standardized medication safety tool.
Washburn NC, Dossett HA, Fritschle AC, Degenkolb KE, Macik MR, Walroth TA. J Patient Saf. 2017 Dec 12; Epub ahead of print].
Inpatient notes: diagnostic excellence starts with an incessant watch.
Dhaliwal G. Ann Intern Med. 2017;167:HO2-HO3.
Learning From Mistakes.
London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764.
Implementation of the surgical safety checklist in South Carolina hospitals is associated with improvement in perceived perioperative safety.
Molina G, Jiang W, Edmondson L, et al. J Am Coll Surg. 2016;222:725-736.e5.
Creating spaces in intensive care for safe communication: a video-reflexive ethnographic study.
Hor SY, Iedema R, Manias E. BMJ Qual Saf. 2014;23:1007-1013.
Emergency department patient safety incident characterization: an observational analysis of the findings of a standardized peer review process.
Jepson ZK, Darling CE, Kotkowski KA, et al. BMC Emerg Med. 2014;14:20.
Multifaceted initiative to reduce "alarm fatigue" on cardiac unit reduces alarms and increases nurse and patient satisfaction.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
Confirming delivery: understanding the role of the hospitalized patient in medication administration safety.
Macdonald MT, Heilemann MV, MacKinnon NJ, et al. Qual Health Res. 2014;24:536-550.
Caregivers' perception of drug administration safety for pediatric oncology patients.
Harris N, Badr LK, Saab R, Khalidi A. J Pediatr Oncol Nurs. 2014;31:95-103.
Improving cancer patient care with combined medication error reviews and morbidity and mortality conferences.
Ranchon F, You B, Salles G, et al. Chemotherapy. 2014;59:330-337.
We know what they did wrong, but not why: the case for 'frame-based' feedback.
Rudolph J, Raemer D, Shapiro J. Clin Teach. 2013;10:186-189.
Intravenous chemotherapy preparation errors: patient safety risks identified in a pan-Canadian exploratory study.
White R, Cassano-Piché A, Fields A, Cheng R, Easty A. J Oncol Pharm Pract. 2014;20:40-46.
Improving resident engagement in quality improvement and patient safety initiatives at the bedside: the Advocate for Clinical Education (ACE).
Schleyer AM, Best JA, McIntyre LK, Ehrmantraut R, Calver P, Goss JR. Am J Med Qual. 2013;28:243-249.
Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions.
van Walraven C, Jennings A, Taljaard M, et al. CMAJ. 2011;183:E1067-E1072.
Misdiagnosis: analysis based on case record review with proposals aimed to improve diagnostic processes.
Neale G, Hogan H, Sevdalis N. Clin Med. 2011;11:317-321.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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