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psnet.ahrq.gov/issue/why-test-results-are-still-getting-lost-follow-qualitative-study-implementation-gaps
June 22, 2022 - Study
Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps.
Citation Text:
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;3…
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psnet.ahrq.gov/issue/electronic-triggers-identify-delays-follow-mammography-harnessing-power-big-data-health-care
September 28, 2016 - Study
Electronic triggers to identify delays in follow-up of mammography: harnessing the power of big data in health care.
Citation Text:
Murphy DR, Meyer AND, Vaghani V, et al. Electronic Triggers to Identify Delays in Follow-Up of Mammography: Harnessing the Power of Big Data in Health…
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psnet.ahrq.gov/issue/impact-teamwork-and-communication-training-interventions-safety-culture-and-patient-safety
October 07, 2020 - Review
Impact of teamwork and communication training interventions on safety culture and patient safety in emergency departments: a systematic review.
Citation Text:
Alsabri M, Boudi Z, Lauque D, et al. Impact of teamwork and communication training interventions on safety culture and pat…
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psnet.ahrq.gov/issue/recommendations-safe-effective-use-adaptive-cds-us-healthcare-system-amia-position-paper
March 24, 2021 - Commentary
Emerging Classic
Recommendations for the safe, effective use of adaptive CDS in the US healthcare system: an AMIA position paper.
Citation Text:
Petersen C, Smith J, Freimuth RR, et al. Recommendations for the safe, effective use of adaptive CDS in th…
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psnet.ahrq.gov/issue/doing-detective-work-find-cancer-how-are-non-specific-symptom-pathways-cancer-investigation
April 05, 2023 - Commentary
Doing 'detective work' to find a cancer: how are non-specific symptom pathways for cancer investigation organised, and what are the implications for safety and quality of care? A multisite qualitative approach.
Citation Text:
Black GB, Nicholson BD, Moreland J-A, et al. Doing …
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psnet.ahrq.gov/issue/safety-implications-different-forms-understaffing-among-nurses-during-covid-19-pandemic
May 05, 2021 - Study
Emerging Classic
Safety implications of different forms of understaffing among nurses during the COVID-19 pandemic.
Citation Text:
Andel SA, Tedone AM, Shen W, et al. Safety implications of different forms of understaffing among nurses during the COVID‐19 …
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psnet.ahrq.gov/issue/interventions-promoting-employee-speaking-within-healthcare-workplaces-systematic-narrative
May 19, 2021 - Review
Classic
Interventions promoting employee "speaking-up" within healthcare workplaces: a systematic narrative review of the international literature.
Citation Text:
Jones A, Blake J, Adams M, et al. Interventions promoting employee “speaking-up” within heal…
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psnet.ahrq.gov/issue/association-between-handover-anesthesiology-care-and-1-year-mortality-among-adults-undergoing
June 08, 2022 - Study
Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac surgery.
Citation Text:
Sun LY, Jones PM, Wijeysundera DN, et al. Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac surger…
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psnet.ahrq.gov/issue/does-root-cause-analysis-improve-patient-safety-systematic-review-department-veterans-affairs
March 24, 2021 - Review
Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs.
Citation Text:
Shah F, Falconer EA, Cimiotti JP. Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs. Qual Manag Healt…
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psnet.ahrq.gov/issue/large-scale-implementation-i-pass-handover-system-academic-medical-centre
March 27, 2018 - Study
Large-scale implementation of the I-PASS handover system at an academic medical centre.
Citation Text:
Shahian DM, McEachern K, Rossi L, et al. Large-scale implementation of the I-PASS handover system at an academic medical centre. BMJ Qual Saf. 2017;26(9):760-770. doi:10.1136/bmjq…
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psnet.ahrq.gov/issue/opioid-prescribing-us-children-and-young-adults-2019
September 30, 2020 - Study
Opioid prescribing to US children and young adults in 2019.
Citation Text:
Chua K-P, Brummett CM, Conti RM, et al. Opioid prescribing to US children and young adults in 2019. Pediatrics. 2021;148(3):e2021051539. doi:10.1542/peds.2021-051539.
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psnet.ahrq.gov/issue/inpatient-fall-prevention-programs-patient-safety-strategy-systematic-review
May 26, 2016 - Review
Inpatient fall prevention programs as a patient safety strategy: a systematic review.
Citation Text:
Miake-Lye IM, Hempel S, Ganz DA, et al. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):390-396. doi:10.732…
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psnet.ahrq.gov/issue/drug-shortage-associated-increase-catheter-related-blood-stream-infection-children
April 24, 2018 - Study
Drug shortage-associated increase in catheter-related blood stream infection in children.
Citation Text:
Ralls MW, Blackwood A, Arnold MA, et al. Drug shortage-associated increase in catheter-related blood stream infection in children. Pediatrics. 2012;130(5):e1369-73. doi:10.1542/…
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psnet.ahrq.gov/issue/how-often-are-potential-patient-safety-events-present-admission
January 26, 2022 - Study
Classic
How often are potential patient safety events present on admission?
Citation Text:
Houchens RL, Elixhauser A, Romano PS. How often are potential patient safety events present on admission? Jt Comm J Qual Patient Saf. 2008;34(3):154-63.
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psnet.ahrq.gov/issue/effect-prescriber-notifications-patients-fatal-overdose-opioid-prescribing-4-12-months
October 06, 2021 - Study
Effect of prescriber notifications of patient’s fatal overdose on opioid prescribing at 4 to 12 months: a randomized clinical trial.
Citation Text:
Doctor JN, Stewart E, Lev R, et al. Effect of prescriber notifications of patient’s fatal overdose on opioid prescribing at 4 to 12 mo…
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psnet.ahrq.gov/issue/long-term-risk-overdose-or-mental-health-crisis-after-opioid-dose-tapering
August 25, 2021 - Study
Long-term risk of overdose or mental health crisis after opioid dose tapering.
Citation Text:
Fenton JJ, Magnan E, Tseregounis IE, et al. Long-term risk of overdose or mental health crisis after opioid dose tapering. JAMA Netw Open. 2022;5(6):e2216726. doi:10.1001/jamanetworkopen.2…
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psnet.ahrq.gov/issue/what-extent-are-patients-involved-researching-safety-acute-mental-healthcare
August 18, 2021 - Review
To what extent are patients involved in researching safety in acute mental healthcare?
Citation Text:
Brierley-Jones L, Ramsey L, Canvin K, et al. To what extent are patients involved in researching safety in acute mental healthcare? Res Involv Engagem. 2022;8(1):8. doi:10.1186/s4…
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psnet.ahrq.gov/issue/national-trends-patient-safety-four-common-conditions-2005-2011
August 03, 2016 - Study
Classic
National trends in patient safety for four common conditions, 2005–2011.
Citation Text:
Wang Y, Eldridge N, Metersky M, et al. National trends in patient safety for four common conditions, 2005-2011. N Engl J Med. 2014;370(4):341-51. doi:10.1056/NE…
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psnet.ahrq.gov/issue/operating-room-icu-patient-handovers-multidisciplinary-human-centered-design-approach
June 27, 2012 - Study
Operating room–to-ICU patient handovers: a multidisciplinary human-centered design approach.
Citation Text:
Segall N, Bonifacio AS, Barbeito A, et al. Operating Room-to-ICU Patient Handovers: A Multidisciplinary Human-Centered Design Approach. Jt Comm J Qual Patient Saf. 2016;42(9)…
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psnet.ahrq.gov/issue/cranky-comments-detecting-clinical-decision-support-malfunctions-through-free-text-override
April 29, 2018 - Study
Cranky comments: detecting clinical decision support malfunctions through free-text override reasons.
Citation Text:
Aaron S, McEvoy DS, Ray S, et al. Cranky comments: detecting clinical decision support malfunctions through free-text override reasons. J Am Med Inform Assoc. 2019;2…