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psnet.ahrq.gov/node/44324/psn-pdf
September 09, 2015 - Prevalence, nature, severity and risk factors for
prescribing errors in hospital inpatients: prospective
study in 20 UK hospitals.
September 9, 2015
Ashcroft DM, Lewis PJ, Tully MP, et al. Prevalence, Nature, Severity and Risk Factors for Prescribing
Errors in Hospital Inpatients: Prospective Study in 20 UK Hospit…
-
psnet.ahrq.gov/node/38435/psn-pdf
February 25, 2009 - Prescribing discrepancies likely to cause adverse drug
events after patient transfer.
February 25, 2009
Boockvar KS, Liu S, Goldstein N, et al. Prescribing discrepancies likely to cause adverse drug events after
patient transfer. Qual Saf Health Care. 2009;18(1):32-6. doi:10.1136/qshc.2007.025957.
https://psnet.ah…
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psnet.ahrq.gov/node/40092/psn-pdf
December 22, 2010 - The value of adding a verbal report to written handoffs on
early readmission following prolonged respiratory failure.
December 22, 2010
Hess DR, Tokarczyk A, O'Malley M, et al. The value of adding a verbal report to written handoffs on early
readmission following prolonged respiratory failure. Chest. 2010;138(6):14…
-
psnet.ahrq.gov/node/845357/psn-pdf
March 29, 2023 - Reducing hospital harm: establishing a command centre
to foster situational awareness.
March 29, 2023
Collins B. Reducing hospital harm: establishing a command centre to foster situational awareness. Healthc
Q. 2022;25(2):75-81. doi:10.12927/hcq.2022.26885.
https://psnet.ahrq.gov/innovation/reducing-hospital-harm-…
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psnet.ahrq.gov/node/40166/psn-pdf
April 03, 2017 - A strategic approach for managing conflict in hospitals:
responding to The Joint Commission leadership
standard—part 1 and part 2.
April 3, 2017
Scott C, Gerardi D. A strategic approach for managing conflict in hospitals: responding to the Joint
Commission leadership standard, Part 1. Jt Comm J Qual Patient Saf. 2…
-
psnet.ahrq.gov/node/46471/psn-pdf
March 20, 2018 - Diagnostic errors in primary care pediatrics: Project
RedDE.
March 20, 2018
Rinke ML, Singh H, Heo M, et al. Diagnostic Errors in Primary Care Pediatrics: Project RedDE. Acad Peds.
2018;18(2):220-227. doi:10.1016/j.acap.2017.08.005.
https://psnet.ahrq.gov/issue/diagnostic-errors-primary-care-pediatrics-project-red…
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psnet.ahrq.gov/node/42788/psn-pdf
January 19, 2014 - Demonstrating high reliability on accountability measures
at The Johns Hopkins Hospital.
January 19, 2014
Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the
Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531-544.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/39970/psn-pdf
January 22, 2017 - Hospital board checklist to improve culture and reduce
central line–associated bloodstream infections.
January 22, 2017
Goeschel CA, Holzmueller CG, Pronovost P. Hospital Board Checklist to improve culture and reduce
central line-associated bloodstream infections. Jt Comm J Qual Patient Saf. 2010;36(11):525-8.
htt…
-
psnet.ahrq.gov/node/37327/psn-pdf
March 03, 2011 - Patterns of technical error among surgical malpractice
claims: an analysis of strategies to prevent injury to
surgical patients.
March 3, 2011
Regenbogen SE, Greenberg CC, Studdert DM, et al. Patterns of technical error among surgical malpractice
claims: an analysis of strategies to prevent injury to surgical pati…
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psnet.ahrq.gov/node/38449/psn-pdf
March 04, 2009 - A model for increasing patient safety in the intensive care
unit: increasing the implementation rates of proven safety
measures.
March 4, 2009
Krimsky WS, Mroz IB, McIlwaine JK, et al. A model for increasing patient safety in the intensive care unit:
increasing the implementation rates of proven safety measures. Q…
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psnet.ahrq.gov/node/45097/psn-pdf
May 09, 2017 - Changes in prescription and over-the-counter medication
and dietary supplement use among older adults in the
United States, 2005 vs 2011.
May 9, 2017
Qato DM, Wilder J, Schumm P, et al. Changes in Prescription and Over-the-Counter Medication and
Dietary Supplement Use Among Older Adults in the United States, 2005 …
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psnet.ahrq.gov/node/38628/psn-pdf
May 13, 2009 - Fast forward rounds: an effective method for teaching
medical students to transition patients safely across care
settings.
May 13, 2009
Ouchida K, LoFaso VM, Capello CF, et al. Fast forward rounds: an effective method for teaching medical
students to transition patients safely across care settings. J Am Geriatr So…
-
psnet.ahrq.gov/node/43224/psn-pdf
June 11, 2014 - Look alike/sound alike drugs: a literature review on
causes and solutions.
June 11, 2014
Ciociano N, Bagnasco L. Look alike/sound alike drugs: a literature review on causes and solutions. Int J
Clin Pharm. 2014;36(2):233-242. doi:10.1007/s11096-013-9885-6.
https://psnet.ahrq.gov/issue/look-alikesound-alike-drugs-l…
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psnet.ahrq.gov/node/42819/psn-pdf
October 31, 2014 - Implementing a national program to reduce catheter-
associated urinary tract infection: a quality improvement
collaboration of state hospital associations, academic
medical centers, professional societies, and
governmental agencies.
October 31, 2014
Fakih MG, George C, Edson B, et al. Implementing a national prog…
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psnet.ahrq.gov/node/46667/psn-pdf
February 22, 2018 - Efficiency and thoroughness trade-offs in high-volume
organisational routines: an ethnographic study of
prescribing safety in primary care.
February 22, 2018
Grant S, Guthrie B. Efficiency and thoroughness trade-offs in high-volume organisational routines: an
ethnographic study of prescribing safety in primary car…
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psnet.ahrq.gov/node/73252/psn-pdf
January 01, 2022 - Why test results are still getting "lost" to follow-up: a
qualitative study of implementation gaps.
May 12, 2021
Zimolzak AJ, Shahid U, Giardina TD, et al. Why test results are still getting "lost" to follow-up: a qualitative
study of implementation gaps. J Gen Intern Med. 2022;37(1):137-144. doi:10.1007/s11606-021…
-
psnet.ahrq.gov/node/73527/psn-pdf
July 28, 2021 - Guidance for health care leaders during the recovery
stage of the COVID-19 pandemic: a consensus statement.
July 28, 2021
Geerts JM, Kinnair D, Taheri P, et al. Guidance for health care leaders during the recovery stage of the
COVID-19 pandemic: a consensus statement. JAMA Netw Open. 2021;4(7):e2120295.
doi:10.100…
-
psnet.ahrq.gov/node/38983/psn-pdf
February 10, 2015 - Improving safety and eliminating redundant tests: cutting
costs in U.S. hospitals.
February 10, 2015
Jha AK, Chan DC, Ridgway AB, et al. Improving safety and eliminating redundant tests: cutting costs in
U.S. hospitals. Health Aff (Millwood). 2009;28(5):1475-1484. doi:10.1377/hlthaff.28.5.1475.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/43723/psn-pdf
October 03, 2017 - Shining a Light: Safer Health Care Through Transparency.
October 3, 2017
Boston, MA: National Patient Safety Foundation Lucian Leape Institute; January 2015.
https://psnet.ahrq.gov/issue/shining-light-safer-health-care-through-transparency
Health care has historically treated data as something to be safeguarded rat…
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psnet.ahrq.gov/node/37613/psn-pdf
March 12, 2008 - Implementing patient safety interventions in your
hospital: what to try and what to avoid.
March 12, 2008
Ranji SR, Shojania KG. Implementing patient safety interventions in your hospital: what to try and what to
avoid. Med Clin North Am. 2008;92(2):275-93, vii-viii. doi:10.1016/j.mcna.2007.10.007.
https://psnet.a…