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psnet.ahrq.gov/issue/tying-loose-ends-discharging-patients-unresolved-medical-issues
February 24, 2011 - Study
Tying up loose ends: discharging patients with unresolved medical issues.
Citation Text:
Moore C, McGinn T, Halm E. Tying up loose ends: discharging patients with unresolved medical issues. Arch Intern Med. 2007;167(12):1305-11.
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psnet.ahrq.gov/issue/medication-administration-errors-urban-mental-health-hospital-direct-observation-study
September 03, 2014 - Study
Medication-administration errors in an urban mental health hospital: a direct observation study.
Citation Text:
Cottney A, Innes J. Medication-administration errors in an urban mental health hospital: a direct observation study. Int J Ment Health Nurs. 2015;24(1):65-74. doi:10.1111…
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psnet.ahrq.gov/issue/prevalence-second-victim-syndrome-and-emotional-distress-pediatric-intensive-care-providers
April 24, 2018 - Study
The prevalence of second victim syndrome and emotional distress in pediatric intensive care providers.
Citation Text:
Wolf MS, Smith K, Basu M, et al. The prevalence of second victim syndrome and emotional distress in pediatric intensive care providers. J Pediatr Intensive Care. 20…
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psnet.ahrq.gov/issue/physicians-perceptions-preparedness-reporting-and-experiences-related-impaired-and
February 10, 2015 - Study
Classic
Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues.
Citation Text:
DesRoches CM, Rao SR, Fromson J, et al. Physicians' perceptions, preparedness for reporting, and experiences relat…
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psnet.ahrq.gov/issue/impacts-using-community-health-volunteers-coach-medication-safety-behaviors-among-rural
September 15, 2011 - Study
The impacts of using community health volunteers to coach medication safety behaviors among rural elders with chronic illnesses.
Citation Text:
Wang C-J, Fetzer SJ, Yang Y-C, et al. The impacts of using community health volunteers to coach medication safety behaviors among rural e…
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psnet.ahrq.gov/issue/value-investments-health-information-technology-us-department-veterans-affairs
February 10, 2015 - Study
The value from investments in health information technology at the U.S. Department of Veterans Affairs.
Citation Text:
Byrne CM, Mercincavage LM, Pan EC, et al. The value from investments in health information technology at the U.S. Department of Veterans Affairs. Health Aff (Millw…
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psnet.ahrq.gov/issue/prescribers-interactions-medication-alerts-point-prescribing-multi-method-situ-investigation
January 07, 2015 - Study
Prescribers' interactions with medication alerts at the point of prescribing: a multi-method, in situ investigation of the human–computer interaction.
Citation Text:
Russ AL, Zillich AJ, McManus S, et al. Prescribers' interactions with medication alerts at the point of prescribin…
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psnet.ahrq.gov/issue/physicians-perspectives-regarding-prescription-drug-monitoring-program-use-within-department
February 17, 2017 - Study
Physicians' perspectives regarding prescription drug monitoring program use within the Department of Veterans Affairs: a multi-state qualitative study.
Citation Text:
Radomski TR, Bixler FR, Zickmund SL, et al. Physicians' Perspectives Regarding Prescription Drug Monitoring Program…
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psnet.ahrq.gov/issue/use-technology-improve-adherence-surgical-safety-checklists-operating-room
December 03, 2014 - Study
Use of technology to improve the adherence to surgical safety checklists in the operating room.
Citation Text:
Pati AB, Mishra TS, Chappity P, et al. Use of technology to improve the adherence to surgical safety checklists in the operating room. Jt Comm J Qual Patient Saf. 2023;49(…
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psnet.ahrq.gov/issue/comparing-outcomes-reporting-and-trigger-tool-methods-capture-adverse-events-emergency
May 04, 2017 - Study
Comparing the outcomes of reporting and trigger tool methods to capture adverse events in the emergency department.
Citation Text:
Lee W-H, Zhang E, Chiang C-Y, et al. Comparing the Outcomes of Reporting and Trigger Tool Methods to Capture Adverse Events in the Emergency Department…
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psnet.ahrq.gov/issue/communication-practices-4-harvard-surgical-services-surgical-safety-collaborative
September 29, 2017 - Study
Communication practices on 4 Harvard surgical services: a surgical safety collaborative.
Citation Text:
Elbardissi AW, Regenbogen SE, Greenberg CC, et al. Communication practices on 4 Harvard surgical services: a surgical safety collaborative. Ann Surg. 2009;250(6):861-5. doi:10.…
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psnet.ahrq.gov/issue/incident-reporting-system-does-not-detect-adverse-drug-events-problem-quality-improvement
February 10, 2011 - Study
Classic
Incident reporting system does not detect adverse drug events: a problem for quality improvement.
Citation Text:
Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events: a problem for quality improvem…
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psnet.ahrq.gov/issue/parent-reported-errors-and-adverse-events-hospitalized-children
June 29, 2009 - Study
Classic
Parent-reported errors and adverse events in hospitalized children.
Citation Text:
Khan A, Furtak SL, Melvin P, et al. Parent-reported errors and adverse events in hospitalized children. JAMA Pediatr. 2016;170(4):e154608. doi:10.1001/jamapediatrics…
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psnet.ahrq.gov/issue/impact-rapid-response-system-delayed-emergency-team-activation-patient-characteristics-and
November 03, 2008 - Study
The impact of Rapid Response System on delayed emergency team activation patient characteristics and outcomes—a follow-up study.
Citation Text:
Calzavacca P, Licari E, Tee A, et al. The impact of Rapid Response System on delayed emergency team activation patient characteristics a…
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psnet.ahrq.gov/issue/clinician-identified-problems-and-solutions-delayed-diagnosis-primary-care-prioritize-study
December 14, 2016 - Study
Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study.
Citation Text:
Car LT, Papachristou N, Bull A, et al. Clinician-identified problems and solutions for delayed diagnosis in primary care: a PRIORITIZE study. BMC Fam Pract. 2016;17…
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psnet.ahrq.gov/issue/multi-stakeholder-consensus-driven-research-agenda-better-understanding-and-supporting
September 01, 2018 - Commentary
A multi-stakeholder consensus-driven research agenda for better understanding and supporting the emotional impact of harmful events on patients and families.
Citation Text:
Bell SK, Etchegaray J, Gaufberg E, et al. A Multi-Stakeholder Consensus-Driven Research Agenda for Bette…
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psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - She was bit slow to reply to questions, but this finding was attributed to the language barrier, as she
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psnet.ahrq.gov/web-mm/case-patient-flow-management
February 23, 2019 - Pressures
May 1, 2007
WebM&M Cases
Language Barrier
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psnet.ahrq.gov/node/867986/psn-pdf
March 24, 2025 - Previously, the biggest barrier was that you could not get compensated for any of this work. … and for post-discharge
follow-up intervention.8 We are hoping that it helps to counteract the cost barrier
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psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overdose-pediatric-patient
October 04, 2023 - While cost may remain a barrier, expanded access is a step in the right direction to combat opioid overdose