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psnet.ahrq.gov/node/38572/psn-pdf
April 22, 2009 - Development and validation of the SURgical PAtient
Safety System (SURPASS) checklist.
April 22, 2009
de Vries EN, Hollmann MW, Smorenburg SM, et al. Development and validation of the SURgical PAtient
Safety System (SURPASS) checklist. Qual Saf Health Care. 2009;18(2):121-6.
doi:10.1136/qshc.2008.027524.
https://p…
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psnet.ahrq.gov/node/43709/psn-pdf
December 04, 2014 - A team-based approach to reducing cardiac monitor
alarms.
December 4, 2014
Dandoy CE, Davies SM, Flesch L, et al. A team-based approach to reducing cardiac monitor alarms.
Pediatrics. 2014;134(6):e1686-e1694. doi:10.1542/peds.2014-1162.
https://psnet.ahrq.gov/issue/team-based-approach-reducing-cardiac-monitor-alar…
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psnet.ahrq.gov/node/844769/psn-pdf
January 01, 2020 - Failure to administer recommended chemotherapy:
acceptable variation or cancer care quality blind spot?
September 18, 2019
Ellis RJ, Schlick CJR, Feinglass J, et al. Failure to administer recommended chemotherapy: acceptable
variation or cancer care quality blind spot? BMJ Qual Saf. 2020;29(2):103-112. doi:10.1136/…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/clinicians-providers/iadapt/allison.pdf
December 19, 2014 - Story Guides – Making Comparative Effectiveness Useful for Vulnerable Patients
Research to …
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psnet.ahrq.gov/node/37346/psn-pdf
March 28, 2012 - Medication administration discrepancies persist despite
electronic ordering.
March 28, 2012
FitzHenry F, Peterson JF, Arrieta M, et al. Medication Administration Discrepancies Persist Despite
Electronic Ordering. J Am Med Inform Assoc. 2007;14(6):756-764. doi:10.1197/jamia.m2359.
https://psnet.ahrq.gov/issue/medic…
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psnet.ahrq.gov/node/43444/psn-pdf
August 27, 2014 - Patient-safety–related hospital deaths in England:
thematic analysis of incidents reported to a national
database, 2010–2012.
August 27, 2014
Donaldson LJ, Panesar S, Darzi A. Patient-safety-related hospital deaths in England: thematic analysis of
incidents reported to a national database, 2010-2012. PLoS Med. 201…
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psnet.ahrq.gov/node/44501/psn-pdf
January 22, 2016 - Patient safety perceptions in pediatric out-of-hospital
emergency care: Children's Safety Initiative.
January 22, 2016
Guise J-M, Meckler G, O'Brien K, et al. Patient Safety Perceptions in Pediatric Out-of-Hospital Emergency
Care: Children's Safety Initiative. J Pediatr. 2015;167(5):1143-8.e1. doi:10.1016/j.jpeds.2…
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psnet.ahrq.gov/node/46678/psn-pdf
January 03, 2018 - Measuring patient safety in real time: an essential method
for effectively improving the safety of care.
January 3, 2018
Classen DC, Griffin FA, Berwick DM. Measuring Patient Safety in Real Time: An Essential Method for
Effectively Improving the Safety of Care. Ann Intern Med. 2017;167(12). doi:10.7326/m17-2202.
h…
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psnet.ahrq.gov/node/45966/psn-pdf
April 05, 2017 - Fundamental Use of Surgical Energy (FUSE): an essential
educational program for operating room safety.
April 5, 2017
Jones SB, Munro MG, Feldman LS, et al. Fundamental Use of Surgical Energy (FUSE): An Essential
Educational Program for Operating Room Safety. Perm J. 2017;21:16-050. doi:10.7812/TPP/16-050.
https://…
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psnet.ahrq.gov/node/50935/psn-pdf
February 26, 2020 - Moving from knowledge to action: improving safety and
quality of care for patients with limited English
proficiency.
February 26, 2020
Fox MT, Godage SK, Kim JM, et al. Moving from knowledge to action: improving safety and quality of care
for patients with limited English proficiency. Clin Pediatr (Phila). 2020;59…
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psnet.ahrq.gov/node/35434/psn-pdf
June 14, 2011 - Turning the medical gaze in upon itself: root cause
analysis and the investigation of clinical error.
June 14, 2011
Iedema RAM, Jorm C, Long D, et al. Turning the medical gaze in upon itself: root cause analysis and the
investigation of clinical error. Soc Sci Med. 2006;62(7):1605-15.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/46532/psn-pdf
July 30, 2018 - Efficiency and safety of speech recognition for
documentation in the electronic health record.
July 30, 2018
Hodgson T, Magrabi F, Coiera E. Efficiency and safety of speech recognition for documentation in the
electronic health record. J Am Med Inform Assoc. 2017;24(6):1127-1133. doi:10.1093/jamia/ocx073.
https://…
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www.ahrq.gov/evidencenow/projects/heart-health/about/stories/in-action/cascades-east.html
March 01, 2021 - New Ideas Lead to Big Changes in Care
Like many small- and medium-sized practices, the team at Cascades East Family Medicine is always searching for ways to improve care. For Cascades East, this meant enrolling in EvidenceNOW, which connected them with a practice facilitator, Mr. Steven Brantley.
In their wor…
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psnet.ahrq.gov/node/48163/psn-pdf
July 31, 2019 - The MedSafer Study: a controlled trial of an electronic
decision support tool for deprescribing in acute care.
July 31, 2019
McDonald EG, Wu PE, Rashidi B, et al. The MedSafer Study: A Controlled Trial of an Electronic Decision
Support Tool for Deprescribing in Acute Care. J Am Geriatr Soc. 2019;67(9):1843-1850.
d…
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psnet.ahrq.gov/node/45914/psn-pdf
March 20, 2018 - Understanding the multidimensional effects of resident
duty hours restrictions: a thematic analysis of published
viewpoints in surgery.
March 20, 2018
Devitt KS, Kim MJ, Conn LG, et al. Understanding the Multidimensional Effects of Resident Duty Hours
Restrictions: A Thematic Analysis of Published Viewpoints in Su…
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psnet.ahrq.gov/node/46981/psn-pdf
May 04, 2019 - Lessons learned from implementing a principled
approach to resolution following patient harm.
May 4, 2019
Smith KM, Smith LL, (Jack) Gentry JC, et al. Lessons learned from implementing a principled approach to
resolution following patient harm. J Patient Saf Risk Manag. 2018;24(2):83-89.
doi:10.1177/25160435188138…
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psnet.ahrq.gov/node/42419/psn-pdf
July 17, 2013 - Health IT Patient Safety Action and Surveillance Plan.
July 17, 2013
Washington, DC: Office of the National Coordinator for Health Information Technology; July 2, 2013.
https://psnet.ahrq.gov/issue/health-it-patient-safety-action-and-surveillance-plan
This report from the Department of Health and Human Services (HH…
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psnet.ahrq.gov/node/45700/psn-pdf
September 01, 2018 - Resolving malpractice claims after tort reform: experience
in a self-insured Texas public academic health system.
September 1, 2018
Sage WM, Harding MC, Thomas EJ. Resolving Malpractice Claims after Tort Reform: Experience in a Self-
Insured Texas Public Academic Health System. Health Serv Res. 2016;51 Suppl 3:2615…
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psnet.ahrq.gov/node/42832/psn-pdf
September 01, 2016 - Overrides of medication-related clinical decision support
alerts in outpatients.
September 1, 2016
Nanji KC, Slight SP, Seger DL, et al. Overrides of medication-related clinical decision support alerts in
outpatients. J Am Med Inform Assoc. 2014;21(3):487-91. doi:10.1136/amiajnl-2013-001813.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/45175/psn-pdf
February 22, 2017 - Improving physician's hand over among oncology staff
using standardized communication tool.
February 22, 2017
Alolayan A, Alkaiyat M, Ali Y, et al. Improving physician's hand over among oncology staff using
standardized communication tool. BMJ Qual Improv Rep. 2017;6(1).
doi:10.1136/bmjquality.u211844.w6141.
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