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psnet.ahrq.gov/issue/incidence-and-types-preventable-adverse-events-elderly-patients-population-based-review
June 23, 2015 - Study
Classic
Incidence and types of preventable adverse events in elderly patients: population based review of medical records.
Citation Text:
Thomas EJ, Brennan TA. Incidence and types of preventable adverse events in elderly patients: population based revie…
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psnet.ahrq.gov/issue/global-trigger-tool-shows-adverse-events-hospitals-may-be-ten-times-greater-previously
February 15, 2011 - Study
Classic
'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured.
Citation Text:
Classen D, Resar RK, Griffin F, et al. 'Global trigger tool' shows that adverse events in hospitals may be ten times grea…
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psnet.ahrq.gov/issue/intervention-decrease-catheter-related-bloodstream-infections-icu
June 16, 2011 - Study
Classic
An intervention to decrease catheter-related bloodstream infections in the ICU.
Citation Text:
Pronovost P, Needham DM, Berenholtz SM, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(2…
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psnet.ahrq.gov/issue/burnout-and-medical-errors-among-american-surgeons
December 21, 2014 - Study
Burnout and medical errors among American surgeons.
Citation Text:
Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000. doi:10.1097/SLA.0b013e3181bfdab3.
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psnet.ahrq.gov/issue/patient-and-family-reporting-system-perceived-ambulatory-note-mistakes-experience-3-us
June 06, 2018 - Study
A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcare centers.
Citation Text:
Bourgeois FC, Fossa A, Gerard M, et al. A patient and family reporting system for perceived ambulatory note mistakes: experience at 3 U.S. healthcar…
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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/issue/culture-change-infection-control-applying-psychological-principles-improve-hand-hygiene
November 21, 2021 - Study
Culture change in infection control: applying psychological principles to improve hand hygiene.
Citation Text:
Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual. 2013;28(4):304…
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psnet.ahrq.gov/issue/patient-harm-resulting-medication-reconciliation-process-failures-study-serious-events
October 07, 2020 - Study
Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals.
Citation Text:
Harper A, Kukielka E, Jones RM. Patient harm resulting from medication reconciliation process failures: a study of serious events rep…
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psnet.ahrq.gov/issue/maternal-and-neonatal-health-care-worker-well-being-and-patient-safety-climate-amid-covid-19
February 01, 2023 - Study
Maternal and neonatal health care worker well-being and patient safety climate amid the COVID-19 pandemic.
Citation Text:
Haidari E, Main EK, Cui X, et al. Maternal and neonatal health care worker well-being and patient safety climate amid the COVID-19 pandemic. J Perinatol. 2021;4…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/kaushal-r-et-al-2003
January 01, 2003 - Kaushal R et al. 2003 "Effects of computerized physician order entry and clinical decision support systems on medication safety - a systematic review."
Reference
Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: …
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psnet.ahrq.gov/issue/does-suggested-diagnosis-general-practitioners-referral-question-impact-diagnostic-reasoning
September 14, 2022 - Study
Does a suggested diagnosis in a general practitioners' referral question impact diagnostic reasoning: an experimental study.
Citation Text:
Staal J, Speelman M, Brand R, et al. Does a suggested diagnosis in a general practitioners’ referral question impact diagnostic reasoning: an …
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psnet.ahrq.gov/issue/changes-perceptions-antibiotic-stewardship-among-neonatal-intensive-care-unit-providers-over
September 29, 2021 - Study
Changes in perceptions of antibiotic stewardship among neonatal intensive care unit providers over the course of a learning collaborative: a prospective, multisite, mixed-methods evaluation.
Citation Text:
Qureshi N, Kroger J, Zangwill KM, et al. Changes in perceptions of antibioti…
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psnet.ahrq.gov/issue/systematic-review-literature-evaluation-handoff-tools-implications-research-and-practice
May 23, 2012 - Review
A systematic review of the literature on the evaluation of handoff tools: implications for research and practice.
Citation Text:
Abraham J, Kannampallil TG, Patel VL. A systematic review of the literature on the evaluation of handoff tools: implications for research and practice. …
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psnet.ahrq.gov/issue/association-intraoperative-anaesthesia-handovers-patient-morbidity-and-mortality-systematic
June 22, 2022 - Review
Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systematic review and meta-analysis.
Citation Text:
Boet S, Djokhdem H, Leir SA, et al. Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systemati…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Prologue_Keyes_Vol3.pdf
June 02, 2025 - Prologue: The Shift toward Performance and Tools
Prologue
The Shift toward Performance and Tools
Margaret A. Keyes, M.A.
The articles in this volume provide a number of perspectives on performance and tools used to
improve the safe delivery of health care. They include a wide variety of approaches that
…
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psnet.ahrq.gov/issue/containing-covid-19-emergency-department-role-improved-case-detection-and-segregation-suspect
May 05, 2021 - Study
Containing COVID-19 in the emergency department: the role of improved case detection and segregation of suspect cases.
Citation Text:
Wee LE, Fua T‐P, Chua YY, et al. Containing COVID-19 in the emergency department: the role of improved case detection and segregation of suspect cas…
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psnet.ahrq.gov/issue/impact-covid-19-inpatient-clinical-emergencies-single-center-experience
February 17, 2021 - Study
Impact of COVID-19 on inpatient clinical emergencies: a single-center experience.
Citation Text:
Mitchell OJL, Neefe S, Ginestra JC, et al. Impact of COVID-19 on inpatient clinical emergencies: a single-center experience. Resusc Plus. 2021;6:100135. doi:10.1016/j.resplu.2021.100135…
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psnet.ahrq.gov/issue/death-suicide-within-1-week-hospital-discharge-retrospective-study-root-cause-analysis
May 04, 2022 - Study
Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports.
Citation Text:
Riblet N, Shiner B, Watts B, et al. Death by Suicide Within 1 Week of Hospital Discharge: A Retrospective Study of Root Cause Analysis Reports. J Nerv Ment Dis…
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psnet.ahrq.gov/issue/medical-team-training-and-coaching-veterans-health-administration-assessment-and-impact-first
December 21, 2014 - Study
Medical team training and coaching in the veterans health administration; assessment and impact on the first 32 facilities in the programme.
Citation Text:
Neily J, Mills PD, Lee P, et al. Medical team training and coaching in the Veterans Health Administration; assessment and im…
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psnet.ahrq.gov/issue/electronic-patient-identification-sample-labeling-reduces-wrong-blood-tube-errors
September 20, 2012 - Study
Emerging Classic
Electronic patient identification for sample labeling reduces wrong blood in tube errors.
Citation Text:
Kaufman RM, Dinh A, Cohn CS, et al. Electronic patient identification for sample labeling reduces wrong blood in tube errors. Transfus…