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psnet.ahrq.gov/node/45959/psn-pdf
June 29, 2017 - Impact of the Opioid Safety Initiative on opioid-related
prescribing in veterans.
June 29, 2017
Lin LA, Bohnert ASB, Kerns RD, et al. Impact of the Opioid Safety Initiative on opioid-related prescribing in
veterans. Pain. 2017;158(5):833-839. doi:10.1097/j.pain.0000000000000837.
https://psnet.ahrq.gov/issue/impact…
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psnet.ahrq.gov/node/43533/psn-pdf
August 28, 2017 - Organizational, cultural, and psychological determinants
of smart infusion pump work arounds: a study of 3 U.S.
health systems.
August 28, 2017
Dunford BB, Perrigino M, Tucker SJ, et al. Organizational, Cultural, and Psychological Determinants of
Smart Infusion Pump Work Arounds: A Study of 3 U.S. Health Systems. …
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psnet.ahrq.gov/node/48061/psn-pdf
June 12, 2019 - Interventions to reduce burnout and improve resilience:
impact on a health system's outcomes.
June 12, 2019
Moffatt-Bruce SD, Nguyen MC, Steinberg B, et al. Interventions to Reduce Burnout and Improve
Resilience: Impact on a Health System's Outcomes. Clin Obstet Gynecol. 2019;62(3):432-443.
doi:10.1097/GRF.0000000…
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psnet.ahrq.gov/node/38288/psn-pdf
February 03, 2011 - Hospital-wide code rates and mortality before and after
implementation of a rapid response team.
February 3, 2011
Chan PS, Khalid A, Longmore LS, et al. Hospital-wide code rates and mortality before and after
implementation of a rapid response team. JAMA. 2008;300(21):2506-13. doi:10.1001/jama.2008.715.
https://ps…
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psnet.ahrq.gov/node/863747/psn-pdf
March 06, 2024 - "Good care is slow enough to be able to pay attention":
primary care time scarcity and patient safety.
March 6, 2024
Satterwhite S, Nguyen M-LT, Honcharov V, et al. "Good care is slow enough to be able to pay attention":
primary care time scarcity and patient safety. J Gen Intern Med. 2024;39(9):1575-1582.
doi:10.…
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psnet.ahrq.gov/node/45979/psn-pdf
April 05, 2017 - Healthcare system-wide implementation of opioid-safety
guideline recommendations: the case of urine drug
screening and opioid-patient suicide- and overdose-
related events in the Veterans Health Administration.
April 5, 2017
Brennan PL, Del Re AC, Henderson PT, et al. Healthcare system-wide implementation of opioi…
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psnet.ahrq.gov/node/39063/psn-pdf
December 17, 2009 - Safety and risk management interventions in hospitals: a
systematic review of the literature.
December 17, 2009
Dückers M, Faber M, Cruijsberg J, et al. Safety and risk management interventions in hospitals: a
systematic review of the literature. Med Care Res Rev. 2009;66(6 Suppl):90S-119S.
doi:10.1177/10775587093…
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psnet.ahrq.gov/node/40450/psn-pdf
December 21, 2014 - Unit-based care teams and the frequency and quality of
physician–nurse communications.
December 21, 2014
Gordon M, Melvin P, Graham DA, et al. Unit-based care teams and the frequency and quality of physician-
nurse communications. Arch Pediatr Adolesc Med. 2011;165(5):424-8. doi:10.1001/archpediatrics.2011.54.
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January 22, 2017 - A proactive risk avoidance system using failure mode and
effects analysis for "same-name" physician orders.
January 22, 2017
Tarpey K, Schaaf E, Lakhani U, et al. A proactive risk avoidance system using failure mode and effects
analysis for "same-name" physician orders. Jt Comm J Qual Patient Saf. 2010;36(10):461-7…
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psnet.ahrq.gov/node/48150/psn-pdf
August 21, 2019 - Communication between primary and secondary care:
deficits and danger.
August 21, 2019
Dinsdale E, Hannigan A, O’Connor R, et al. Communication between primary and secondary care: deficits
and danger. Fam Pract. 2019;17(1):63-68. doi:10.1093/fampra/cmz037.
https://psnet.ahrq.gov/issue/communication-between-primary…
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psnet.ahrq.gov/node/39001/psn-pdf
April 04, 2011 - Timely follow-up of abnormal diagnostic imaging test
results in an outpatient setting: are electronic medical
records achieving their potential?
April 4, 2011
Singh H, Thomas EJ, Mani S, et al. Timely follow-up of abnormal diagnostic imaging test results in an
outpatient setting: are electronic medical records ach…
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psnet.ahrq.gov/node/40907/psn-pdf
December 08, 2011 - Reporting of sentinel events in Swedish hospitals: a
comparison of severe adverse events reported by
patients and providers.
December 8, 2011
Öhrn A, Elfström J, Liedgren C, et al. Reporting of sentinel events in Swedish hospitals: a comparison of
severe adverse events reported by patients and providers. Jt Comm J…
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psnet.ahrq.gov/node/44750/psn-pdf
January 06, 2016 - Simulation in the executive suite: lessons learned for
building patient safety leadership.
January 6, 2016
Rosen MA, Goeschel CA, Che X-X, et al. Simulation in the Executive Suite: Lessons Learned for Building
Patient Safety Leadership. Simul Healthc. 2015;10(6):372-377.
https://psnet.ahrq.gov/issue/simulation-exe…
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psnet.ahrq.gov/node/43367/psn-pdf
May 01, 2015 - Promoting Patient Safety Through Effective Health
Information Technology Risk Management.
May 1, 2015
Schneider EC, Ridgely MS, Meeker D, Hunter LE, Khodyakov D, Rudin R. RAND Health. Washington, DC:
Office of the National Coordinator for Health Information Technology; May 2014. RR-654-DHHSNCH.
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psnet.ahrq.gov/node/44302/psn-pdf
August 04, 2015 - The Global Comparators project: international
comparison of 30-day in-hospital mortality by day of the
week.
August 4, 2015
Ruiz M, Bottle A, Aylin PP. The Global Comparators project: international comparison of 30-day in-hospital
mortality by day of the week. BMJ Qual Saf. 2015;24(8):492-504. doi:10.1136/bmjqs-20…
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psnet.ahrq.gov/node/42211/psn-pdf
April 24, 2013 - An organizational assessment of disruptive clinician
behavior: findings and implications.
April 24, 2013
Walrath JM, Dang D, Nyberg D. An Organizational Assessment of Disruptive Clinician Behavior. J Nurs
Care Qual. 2012;28(2):110-121. doi:10.1097/ncq.0b013e318270d2ba.
https://psnet.ahrq.gov/issue/organizational-a…
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psnet.ahrq.gov/node/47973/psn-pdf
July 18, 2019 - Transition planning for the senior surgeon: guidance and
recommendations from the Society of Surgical Chairs.
July 18, 2019
Rosengart TK, Doherty G, Higgins R, et al. Transition Planning for the Senior Surgeon: Guidance and
Recommendations From the Society of Surgical Chairs. JAMA Surg. 2019;154(7):647-653.
doi:10…
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psnet.ahrq.gov/node/764396/psn-pdf
March 02, 2022 - Family Input for Quality and Safety (FIQS): using mobile
technology for in-hospital reporting from families and
patients.
March 2, 2022
Bardach NS, Stotts JR, Fiore DM, et al. Family Input for Quality and Safety (FIQS): Using mobile
technology for in?hospital reporting from families and patients. J Hosp Med. 2022;…
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psnet.ahrq.gov/node/43301/psn-pdf
May 01, 2015 - Walkrounds in practice: corrupting or enhancing a quality
improvement intervention? A qualitative study.
May 1, 2015
Martin G, Ozieranski P, Willars J, et al. Walkrounds in practice: corrupting or enhancing a quality
improvement intervention? A qualitative study. Jt Comm J Qual Patient Saf. 2014;40(7):303-310.
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July 30, 2014 - Effectiveness of the surgical safety checklist in correcting
errors: a literature review applying Reason's Swiss
cheese model.
July 30, 2014
Collins SJ, Newhouse R, Porter J, et al. Effectiveness of the surgical safety checklist in correcting errors: a
literature review applying Reason's Swiss cheese model. AORN J…