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  1. psnet.ahrq.gov/issue/change-what-can-actually-make-tough-times-better-patient-centred-patient-safety-intervention
    September 24, 2017 - Study "Change is what can actually make the tough times better": a patient-centred patient safety intervention delivered in collaboration with hospital volunteers. Citation Text: Louch G, Mohammed MA, Hughes L, et al. "Change is what can actually make the tough times better": A patient-c…
  2. psnet.ahrq.gov/issue/detecting-unapproved-abbreviations-electronic-medical-record
    August 08, 2018 - Study Detecting unapproved abbreviations in the electronic medical record. Citation Text: Capraro A, Stack AM, Harper MB, et al. Detecting unapproved abbreviations in the electronic medical record. Jt Comm J Qual Patient Saf. 2012;38(4):178-183. doi:10.1016/s1553-7250(12)38023-9. Copy …
  3. psnet.ahrq.gov/issue/interprofessional-handover-and-patient-safety-anaesthesia-observational-study-handovers
    April 18, 2011 - Study Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room. Citation Text: Smith AF, Pope C, Goodwin D, et al. Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery r…
  4. psnet.ahrq.gov/issue/quality-improvements-decreasing-medication-administration-errors-made-nursing-staff-academic
    March 24, 2019 - Study Quality improvements in decreasing medication administration errors made by nursing staff in an academic medical center hospital: a trend analysis during the journey to Joint Commission International accreditation and in the post-accreditation era. Citation Text: Wang H-F, Jin J-F,…
  5. psnet.ahrq.gov/issue/risk-factors-wrong-site-surgery-study-1166-reports-informed-consent-and-schedule-errors
    January 20, 2021 - Study Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors. Citation Text: Taylor MA, Yonash RA. Risk factors for wrong-site surgery: a study of 1,166 reports of informed consent and schedule errors. Patient Safety. 2024;6(1):1-11. doi:10.…
  6. psnet.ahrq.gov/issue/clinicians-satisfaction-cpoe-ease-use-and-effect-clinicians-workflow-efficiency-and
    August 10, 2022 - Study Clinicians' satisfaction with CPOE ease of use and effect on clinicians' workflow, efficiency and medication safety. Citation Text: Khajouei R, Wierenga PC, Hasman A, et al. Clinicians satisfaction with CPOE ease of use and effect on clinicians' workflow, efficiency and medicatio…
  7. psnet.ahrq.gov/innovation/improving-formal-incivility-reporting-ambulatory-oncology-implementing-civic-duty
    March 14, 2022 - EMERGING INNOVATIONS Improving formal incivility reporting in ambulatory oncology: implementing the CIVIC Duty program. Citation Text: Gordon JN. Improving formal incivility reporting in ambulatory oncology: implementing the CIVIC Duty program. Clin J Oncol Nurs. 2023;27(6):602-606. doi:10.1188/23…
  8. psnet.ahrq.gov/issue/hospitalwide-adverse-drug-events-and-after-limiting-weekly-work-hours-medical-residents-80
    May 04, 2010 - Study Hospitalwide adverse drug events before and after limiting weekly work hours of medical residents to 80. Citation Text: Mycyk MB, McDaniel MR, Fotis MA, et al. Hospitalwide adverse drug events before and after limiting weekly work hours of medical residents to 80. Am J Health Sys…
  9. psnet.ahrq.gov/issue/identifying-and-characterizing-preventable-adverse-drug-events-prioritizing-pharmacist
    July 15, 2010 - Study Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospitals. Citation Text: Jeon N, Staley B, Johns T, et al. Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospital…
  10. psnet.ahrq.gov/issue/suboptimal-compliance-surgical-safety-checklists-colorado-prospective-observational-study
    May 23, 2018 - Study Suboptimal compliance with surgical safety checklists in Colorado: a prospective observational study reveals differences between surgical specialties. Citation Text: Biffl WL, Gallagher AW, Pieracci FM, et al. Suboptimal compliance with surgical safety checklists in Colorado: A pro…
  11. psnet.ahrq.gov/issue/can-preventable-adverse-events-be-predicted-among-hospitalized-older-patients-development-and
    March 18, 2013 - Study Can preventable adverse events be predicted among hospitalized older patients? The development and validation of a predictive model. Citation Text: Van De Steeg L, Langelaan M, Wagner C. Can preventable adverse events be predicted among hospitalized older patients? The development …
  12. psnet.ahrq.gov/web-mm/lethal-cap
    December 19, 2018 - Lethal Cap Citation Text: Schillinger D. Lethal Cap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Do…
  13. psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
    January 01, 2015 - Annual Perspective Patient Safety and Opioid Medications Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2016  View more articles from the same authors. Citation Text: Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. Ro…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33834/psn-pdf
    May 22, 2017 - Opioid Overdose as a Patient Safety Problem May 22, 2017 Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem Perspective Opioids serve a valuable role in the treatment of acute pain and pain associat…
  15. psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
    July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience Karen Frush, MD | May 1, 2005  View more articles from the same authors. Citation Text: Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
  16. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
    June 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case June 2005 Getting to the Root of the Matter Source and Credits This presentation is based on the June 2005 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Scott Flanders, MD; Sa…
  17. psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
    March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety Sara J. Singer, MBA, PhD | September 1, 2013  View more articles from the same authors. Citation Text: Singer SJ. What We've Learned About Leveraging Leadership a…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49626/psn-pdf
    May 01, 2011 - Outbreak May 1, 2011 Rothman R, Stapleton S. Outbreak. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/outbreak The Case A 36-year-old healthy man developed an acute febrile illness associated with a vesicular rash. He presented to an urgent care clinic where he was diagnosed with varicella infection ("chic…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60168/psn-pdf
    March 25, 2020 - Right Electrocardiogram, Wrong Patient March 25, 2020 Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient The Cases Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49628/psn-pdf
    June 01, 2011 - Routine Goes Awry June 1, 2011 Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/routine-goes-awry The Case A 6-year-old girl with a history of asthma and chronic adenotonsillitis was referred to a surgeon and scheduled for a tonsillectomy and adenoidectomy. She was in ot…

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