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psnet.ahrq.gov/node/34870/psn-pdf
April 18, 2016 - Unintended medication discrepancies at the time of
hospital admission.
April 18, 2016
Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital
admission. Arch Intern Med. 2005;165(4):424-9.
https://psnet.ahrq.gov/issue/unintended-medication-discrepancies-time-hospita…
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psnet.ahrq.gov/node/34731/psn-pdf
July 08, 2016 - Crossing the Quality Chasm: A New Health System for the
21st Century.
July 8, 2016
Committee on Quality of Health Care in America, Institute of Medicine. Washington DC: National
Academies Press; 2001. ISBN: 9780309072809.
https://psnet.ahrq.gov/issue/crossing-quality-chasm-new-health-system-21st-century
Following…
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psnet.ahrq.gov/node/72657/psn-pdf
January 20, 2021 - Establishing a multi-institutional quality and patient
safety consortium: collaboration across affiliates in a
community-based medical school.
January 20, 2021
Hillman E, Paul J, Neustadt M, et al. Establishing a multi-institutional quality and patient safety consortium:
collaboration across affiliates in a commun…
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psnet.ahrq.gov/node/837031/psn-pdf
May 04, 2022 - Indicators for implementation outcome monitoring of
reporting and learning systems in hospitals: an
underestimated need for patient safety.
May 4, 2022
Kuske S, Willmeroth T, Schneider J, et al. Indicators for implementation outcome monitoring of reporting
and learning systems in hospitals: an underestimated need …
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psnet.ahrq.gov/node/836822/psn-pdf
March 30, 2022 - Leveraging a safety event management system to
improve organizational learning and safety culture.
March 30, 2022
Dawson R, Saulnier T, Campbell A, et al. Leveraging a safety event management system to improve
organizational learning and safety culture. Hosp Pediatr. 2022;12(4):407-417. doi:10.1542/hpeds.2021-
006…
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psnet.ahrq.gov/node/836915/psn-pdf
April 13, 2022 - Workarounds in electronic health record systems and the
revised Sociotechnical Electronic Health Record
Workaround Analysis Framework: scoping review.
April 13, 2022
Blijleven V, Hoxha F, Jaspers MWM. Workarounds in electronic health record systems and the revised
sociotechnical Electronic Health Record workaround…
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psnet.ahrq.gov/node/73567/psn-pdf
August 04, 2021 - Pharmacist-led educational interventions provided to
healthcare providers to reduce medication errors: a
systematic review and meta-analysis.
August 4, 2021
Jaam M, Naseralallah LM, Hussain TA, et al. Pharmacist-led educational interventions provided to
healthcare providers to reduce medication errors: a systemati…
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psnet.ahrq.gov/node/849610/psn-pdf
May 31, 2023 - Implementation of ED I-PASS as a standardized handoff
tool in the pediatric emergency department.
May 31, 2023
Yanni E, Calaman S, Wiener E, et al. Implementation of ED I-PASS as a standardized handoff tool in the
pediatric emergency department. J Healthc Qual. 2023;45(3):140-147.
doi:10.1097/jhq.0000000000000374.…
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psnet.ahrq.gov/node/837304/psn-pdf
June 01, 2022 - Does standardisation improve post-operative anaesthesia
handoffs? Meta-analyses on provider, patient,
organisational, and handoff outcomes.
June 1, 2022
Lazzara EH, Simonson RJ, Gisick LM, et al. Does standardisation improve post-operative anaesthesia
handoffs? Meta-analyses on provider, patient, organisational, a…
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psnet.ahrq.gov/node/838252/psn-pdf
October 05, 2022 - A longitudinal study of a multifaceted intervention to
reduce newborn falls while preserving rooming-in on a
mother-baby unit.
October 5, 2022
Whatley C, Schlogl J, Whalen BL, et al. A longitudinal study of a multifaceted intervention to reduce
newborn falls while preserving rooming-in on a mother-baby unit. Jt Co…
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psnet.ahrq.gov/node/73413/psn-pdf
June 23, 2021 - Interventions to reduce pediatric prescribing errors in
professional healthcare settings: a systematic review of
the last decade.
June 23, 2021
Koeck JA, Young NJ, Kontny U, et al. Interventions to Reduce Pediatric Prescribing Errors in Professional
Healthcare Settings: A Systematic Review of the Last Decade. Pedi…
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psnet.ahrq.gov/node/73563/psn-pdf
August 04, 2021 - Understanding complaints made about surgical
departments in a UK district general hospital.
August 4, 2021
Claydon O, Keeler B, Khanna A. Understanding complaints made about surgical departments in a UK
district general hospital. Int J Qual Health Care. 2021;33(3). doi:10.1093/intqhc/mzab095.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/845630/psn-pdf
March 08, 2023 - The effect of transitions intervention to ensure patient
safety and satisfaction when transferred from hospital to
home health care-a systematic review.
March 8, 2023
Oksholm T, Gissum KR, Hunskår I, et al. The effect of transitions intervention to ensure patient safety and
satisfaction when transferred from hospi…
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psnet.ahrq.gov/node/74034/psn-pdf
November 03, 2021 - Logo
Adaptation and implementation of the WHO Safe
Childbirth Checklist around the world.
November 3, 2021
Molina RL, Benski A-C, Bobanski L, et al. Adaptation and implementation of the WHO Safe Childbirth
Checklist around the world. Implement Sci Commun. 2021;2(1):76. doi:10.1186/s43058-021-00176-z.
https://psne…
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psnet.ahrq.gov/node/853429/psn-pdf
September 13, 2023 - Multifaceted intervention to improve patient safety
incident reporting in intensive care units.
September 13, 2023
Griffeth EM, Gajic O, Schueler N, et al. Multifaceted intervention to improve patient safety incident reporting
in intensive care units. J Patient Saf. 2023;19(7):422-428. doi:10.1097/pts.0000000000001…
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psnet.ahrq.gov/node/33932/psn-pdf
May 27, 2011 - Preventable anesthesia mishaps: a study of human
factors.
May 27, 2011
Cooper JB, Newbower RS, Long CD, et al. Preventable anesthesia mishaps: a study of human factors.
Anesthesiology. 1978;49(6):399-406.
https://psnet.ahrq.gov/issue/preventable-anesthesia-mishaps-study-human-factors
This study reports on the ret…
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psnet.ahrq.gov/node/34982/psn-pdf
July 14, 2010 - Development of the ICU safety reporting system.
July 14, 2010
Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1(1):23-32.
https://psnet.ahrq.gov/issue/development-icu-safety-reporting-system
This AHRQ-funded study describes the development of a Web-based, voluntary, and anonymous reporting
system. T…
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psnet.ahrq.gov/node/35553/psn-pdf
July 03, 2013 - Maximizing the Use of State Adverse Event Data to
Improve Patient Safety.
July 3, 2013
Rosenthal J, Booth M. National Academy for State Health Policy; 2005.
https://psnet.ahrq.gov/issue/maximizing-use-state-adverse-event-data-improve-patient-safety
This report, generated by the National Academy for State Health Po…
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psnet.ahrq.gov/node/34800/psn-pdf
December 23, 2008 - A classification system for incidents and accidents in the
health-care system.
December 23, 2008
Runciman WB, Helps SC, Sexton EJ, et al. A classification for incidents and accidents in the health-care
system. J Qual Clin Pract. 1998;18(3):199-211.
https://psnet.ahrq.gov/issue/classification-system-incidents-and-a…
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psnet.ahrq.gov/node/46900/psn-pdf
August 29, 2018 - Developing agreement on never events in primary care
dentistry: an international eDelphi study.
August 29, 2018
Ensaldo-Carrasco E, Carson-Stevens A, Cresswell K, et al. Developing agreement on never events in
primary care dentistry: an international eDelphi study. Br Dent J. 2018;224(9):733-740.
doi:10.1038/sj.bd…