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9481. The Top Six: standardized safety practices in U.S. Army Medical Department treatment facilities worldwide. | PSNet
      psnet.ahrq.gov/issue/top-six-standardized-safety-practices-us-army-medical-department-treatment-facilities
      March 18, 2020 - Study The Top Six: standardized safety practices in U.S. Army Medical Department treatment facilities worldwide. Citation Text: Hartstein B, Munante M, Toor PA. The Top Six: Standardized safety practices in U.S. Army Medical Department treatment facilities worldwide. NEJM Catal Innov Car…

9482. Medication report reduces number of medication errors when elderly patients are discharged from hospital. | PSNet
      psnet.ahrq.gov/issue/medication-report-reduces-number-medication-errors-when-elderly-patients-are-discharged
      February 04, 2009 - Study Medication report reduces number of medication errors when elderly patients are discharged from hospital. Citation Text: Midlöv P, Holmdahl L, Eriksson T, et al. Medication report reduces number of medication errors when elderly patients are discharged from hospital. Pharm World…

9483. What happens when healthcare innovations collide? | PSNet
      psnet.ahrq.gov/issue/what-happens-when-healthcare-innovations-collide
      December 06, 2017 - Commentary What happens when healthcare innovations collide? Citation Text: Pendharkar SR, Woiceshyn J, da Silveira GJC, et al. What happens when healthcare innovations collide? BMJ Qual Saf. 2016;25(1):9-13. doi:10.1136/bmjqs-2015-004441. Copy Citation Format: DOI Google S…

9484. Medication errors in paediatric outpatients. | PSNet
      psnet.ahrq.gov/issue/medication-errors-paediatric-outpatients
      December 15, 2011 - Study Medication errors in paediatric outpatients. Citation Text: Kaushal R, Goldmann DA, Keohane CA, et al. Medication errors in paediatric outpatients. BMJ Qual Saf. 2010;19(6). doi:10.1136/qshc.2008.031179. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML…

9485. Patients use an internet technology to report when things go wrong. | PSNet
      psnet.ahrq.gov/issue/patients-use-internet-technology-report-when-things-go-wrong
      July 21, 2009 - Study Patients use an internet technology to report when things go wrong. Citation Text: Wasson JH, MacKenzie TA, Hall M. Patients use an internet technology to report when things go wrong. Qual Saf Health Care. 2007;16(3):213-5. Copy Citation Format: Google Scholar PubMe…

9486. Toolkit 1. Suspected UTI SBAR Toolkit | Agency for Healthcare Research and Quality
      www.ahrq.gov/nhguide/toolkits/determine-whether-to-treat/toolkit1-suspected-uti-sbar.html
      November 01, 2024 - Toolkit 1. Suspected UTI SBAR Toolkit Toolkit Effectiveness A study in 12 nursing homes in Texas found that using the Suspected UTI SBAR form reduced antibiotic prescriptions for asymptomatic bacteriuria by about one-third. 1 Overview of the Toolkit Why Should a Nursing Home Use the Suspected UTI SBAR Toolkit? …

9487. The effect of prescriber education on medication-related patient harm in the hospital: a systematic review. | PSNet
      psnet.ahrq.gov/issue/effect-prescriber-education-medication-related-patient-harm-hospital-systematic-review
      January 07, 2015 - Review The effect of prescriber education on medication-related patient harm in the hospital: a systematic review. Citation Text: Bos JM, van den Bemt PMLA, de Smet PAGM, et al. The effect of prescriber education on medication-related patient harm in the hospital: a systematic review. Br…

9488. Defining health information technology–related errors: new developments since To Err Is Human. | PSNet
      psnet.ahrq.gov/issue/defining-health-information-technology-related-errors-new-developments-err-human
      December 06, 2023 - Commentary Classic Defining health information technology–related errors: new developments since To Err Is Human. Citation Text: Sittig DF, Singh H. Defining health information technology-related errors: new developments since to err is human. Arch Intern Med.…

9489. Improving safety during transitions of care through the use of electronic referral loops to receive and reconcile health information. | PSNet
      psnet.ahrq.gov/issue/improving-safety-during-transitions-care-through-use-electronic-referral-loops-receive-and
      October 19, 2022 - Study Improving safety during transitions of care through the use of electronic referral loops to receive and reconcile health information. Citation Text: Allen G, Setzer J, Jones R, et al. Improving safety during transitions of care through the use of electronic referral loops to receiv…

9490. Double checking: a second look. | PSNet
      psnet.ahrq.gov/issue/double-checking-second-look
      August 28, 2017 - Study Double checking: a second look. Citation Text: Hewitt T, Chreim S, Forster AJ. Double checking: a second look. J Eval Clin Pract. 2016;22(2):267-74. doi:10.1111/jep.12468. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…

9491. Human error and the problem of causality in analysis of accidents. | PSNet
      psnet.ahrq.gov/issue/human-error-and-problem-causality-analysis-accidents
      August 25, 2021 - Commentary Classic Human error and the problem of causality in analysis of accidents. Citation Text: Rasmussen J. Human error and the problem of causality in analysis of accidents. Philos Trans R Soc Lond B Biol Sci. 1990;327(1241):449-462. Copy Citation …

9492. Closing the loop with ambulatory staff on safety reports. | PSNet
      psnet.ahrq.gov/issue/closing-loop-ambulatory-staff-safety-reports
      April 22, 2016 - Study Closing the loop with ambulatory staff on safety reports. Citation Text: Williams S, Fiumara K, Kachalia A, et al. Closing the Loop with Ambulatory Staff on Safety Reports. Jt Comm J Qual Saf. 2020;46(1):44-50. doi:10.1016/j.jcjq.2019.09.009. Copy Citation Format: DOI…

9493. An observational study of adult admissions to a medical ICU due to adverse drug events. | PSNet
      psnet.ahrq.gov/issue/observational-study-adult-admissions-medical-icu-due-adverse-drug-events
      January 28, 2015 - Study An observational study of adult admissions to a medical ICU due to adverse drug events. Citation Text: Jolivot P-A, Pichereau C, Hindlet P, et al. An observational study of adult admissions to a medical ICU due to adverse drug events. Ann Intensive Care. 2016;6(1):9. doi:10.1186/s1…

9494. System planning for modern-day Just Culture to mitigate worker distress and second victim response. | PSNet
      psnet.ahrq.gov/issue/system-planning-modern-day-just-culture-mitigate-worker-distress-and-second-victim-response
      July 19, 2023 - Commentary System planning for modern-day Just Culture to mitigate worker distress and second victim response. Citation Text: Sells JR, Cole I, Dharmasukrit C, et al. System planning for modern-day Just Culture to mitigate worker distress and second victim response. BMJ Lead. 2024;8(2):1…

9495. Battling alarm fatigue in the pediatric intensive care unit. | PSNet
      psnet.ahrq.gov/issue/battling-alarm-fatigue-pediatric-intensive-care-unit
      July 22, 2020 - Commentary Battling alarm fatigue in the pediatric intensive care unit. Citation Text: Herrera H, Wood D. Battling alarm fatigue in the pediatric intensive care unit. Crit Care Nurs Clin North Am. 2023;35(3):347-355. doi:10.1016/j.cnc.2023.05.003. Copy Citation Format: DOI …

9496. CANDOR Event Checklist | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist4.html
      August 01, 2022 - CANDOR Event Checklist AHRQ Communication and Optimal Resolution Toolkit Purpose: To provide a checklist for the required actions that need to be taken following an event. Who should use this tool?   The Communication and Optimal Resolution (CANDOR) Response Team or designee, unless otherwise indicated. …

9497. Mod4-Event-Checklist (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-event-checklist.pdf
      April 01, 2016 - Purpose: To provide a checklist for the required actions that need to be taken following an event. Who should use this tool? The Communication and Optimal Resolution Toolkit (CANDOR) Response Team or designee, unless otherwise indicated. How to use this tool: Use the checklist to ensure that appropriate action is t…

9498. Introduction | Agency for Healthcare Research and Quality
      www.ahrq.gov/patient-safety/settings/hospital/match/intro.html
      July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Introduction Previous Page Next Page Table of Contents Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation Introduction Chapter 1. Building the Project Founda…

9499. Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surgery? | PSNet
      psnet.ahrq.gov/issue/patient-participation-surgical-site-marking-can-be-additional-tool-help-avoid-wrong-site
      March 14, 2022 - Study Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surgery? Citation Text: Bergal LM, Schwarzkopf R, Walsh M, et al. Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surger…

9500. An acetaminophen icon helps reduce medication decision errors in an experimental setting. | PSNet
      psnet.ahrq.gov/issue/acetaminophen-icon-helps-reduce-medication-decision-errors-experimental-setting
      January 12, 2022 - Study An acetaminophen icon helps reduce medication decision errors in an experimental setting. Citation Text: Shiffman S, Cotton H, Jessurun C, et al. An acetaminophen icon helps reduce medication decision errors in an experimental setting. J Am Pharm Assoc (2003). 2016;56(5):495-503.e4…