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  1. psnet.ahrq.gov/issue/systems-approach-sharp-end
    April 21, 2021 - Commentary The systems approach at the sharp end. Citation Text: Cross SRH. The systems approach at the sharp end. Future Healthc J. 2019;5(3):176-180. doi:10.7861/futurehosp.5-3-176. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
  2. psnet.ahrq.gov/issue/safety-through-redundancy-case-study-hospital-patient-transfers
    November 03, 2015 - Study Safety through redundancy: a case study of in-hospital patient transfers. Citation Text: Ong M-S, Coiera E. Safety through redundancy: a case study of in-hospital patient transfers. Qual Saf Health Care. 2010;19(5):e32. doi:10.1136/qshc.2009.035972. Copy Citation Format: …
  3. psnet.ahrq.gov/issue/last-orders-follow-tests-ordered-day-hospital-discharge
    November 03, 2015 - Study Last orders: follow-up of tests ordered on the day of hospital discharge. Citation Text: Ong M-S, Magrabi F, Jones G, et al. Last Orders: Follow-up of Tests Ordered on the Day of Hospital Discharge. Arch Intern Med. 2012;172(17):1347-9. doi:10.1001/archinternmed.2012.2836. Copy C…
  4. psnet.ahrq.gov/issue/development-web-based-surgical-booking-and-informed-consent-system-reduce-potential-error-and
    November 16, 2022 - Study Development of a Web-based surgical booking and informed consent system to reduce the potential for error and improve communication. Citation Text: Siracuse JJ, Benoit E, Burke J, et al. Development of a Web-based surgical booking and informed consent system to reduce the potential…
  5. psnet.ahrq.gov/issue/reasons-provided-prescribers-when-overriding-drug-drug-interaction-alerts
    April 27, 2010 - Study Reasons provided by prescribers when overriding drug–drug interaction alerts. Citation Text: Grizzle AJ, Mahmood MH, Ko Y, et al. Reasons provided by prescribers when overriding drug-drug interaction alerts. Am J Manag Care. 2007;13(10):573-578. Copy Citation Format: …
  6. psnet.ahrq.gov/issue/medical-morbidity-and-mortality-conferences-past-present-and-future
    November 30, 2022 - Review Medical morbidity and mortality conferences: past, present and future. Citation Text: George J. Medical morbidity and mortality conferences: past, present and future. Postgrad Med J. 2017;93(1097):148-152. doi:10.1136/postgradmedj-2016-134103. Copy Citation Format: D…
  7. psnet.ahrq.gov/issue/experiences-health-professionals-who-conducted-root-cause-analyses-after-undergoing-safety
    June 14, 2011 - Study Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Citation Text: Braithwaite J, Westbrook MT, Mallock NA, et al. Experiences of health professionals who conducted root cause analyses after undergoing a safety im…
  8. psnet.ahrq.gov/issue/medication-errors-and-adverse-drug-events-pediatric-inpatients
    January 19, 2011 - Study Classic Medication errors and adverse drug events in pediatric inpatients. Citation Text: Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114-20. Copy Citation Format: …
  9. psnet.ahrq.gov/issue/abbreviation-use-decreases-effective-clinical-communication-and-can-compromise-patient-safety
    October 29, 2017 - Commentary Abbreviation use decreases effective clinical communication and can compromise patient safety. Citation Text: Parry D, Odedra A, Fagbohun M, et al. Abbreviation use decreases effective clinical communication and can compromise patient safety. Br J Oral Maxillofac Surg. 2023;61…
  10. digital.ahrq.gov/principal-investigator/ward-marcia
    January 01, 2023 - Ward, Marcia Patient safety outcomes in small urban and small rural hospitals. Citation Vartak S, Ward MM, Vaughn TE. Patient safety outcomes in small urban and small rural hospitals. J Rural Health 2010 Winter; 26(1):58-66. Principal Investigator Ward, Marcia …
  11. psnet.ahrq.gov/issue/understanding-test-results-follow-ambulatory-setting-analysis-multiple-perspectives
    May 20, 2019 - Study Understanding test results follow-up in the ambulatory setting: analysis of multiple perspectives. Citation Text: Ai A, Desai S, Shellman A, et al. Understanding Test Results Follow-Up in the Ambulatory Setting: Analysis of Multiple Perspectives. Jt Comm J Qual Patient Saf. 2018;44…
  12. psnet.ahrq.gov/issue/comparison-military-and-civilian-methods-determining-potentially-preventable-deaths
    October 19, 2022 - Review Comparison of military and civilian methods for determining potentially preventable deaths: a systematic review. Citation Text: Janak JC, Sosnov JA, Bares JM, et al. Comparison of Military and Civilian Methods for Determining Potentially Preventable Deaths: A Systematic Review. JA…
  13. psnet.ahrq.gov/issue/intentional-rounding-integrative-literature-review
    October 08, 2016 - Review Intentional rounding—an integrative literature review. Citation Text: Ryan L, Jackson D, Woods C, et al. Intentional rounding - An integrative literature review. J Adv Nurs. 2019;75(6):1151-1161. doi:10.1111/jan.13897. Copy Citation Format: DOI Google Scholar PubMed …
  14. psnet.ahrq.gov/issue/understanding-barriers-physician-error-reporting-and-disclosure-systemic-approach-systemic
    January 12, 2022 - Review Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem. Citation Text: Perez B, Knych SA, Weaver SJ, et al. Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem…
  15. psnet.ahrq.gov/issue/systems-approach-suicide-prevention-strengthening-culture-practice-and-education
    July 10, 2024 - Commentary Systems approach to suicide prevention: strengthening culture, practice, and education. Citation Text: Pisani AR, Boudreaux ED. Systems approach to suicide prevention: strengthening culture, practice, and education. Focus (Am Psychiatr Publ). 2023;21(2):152-159. doi:10.1176/ap…
  16. psnet.ahrq.gov/issue/lessons-learned-implementation-computerized-provider-order-entry-5-community-hospitals
    December 31, 2014 - Study Lessons learned from implementation of computerized provider order entry in 5 community hospitals: a qualitative study. Citation Text: Simon SR, Keohane CA, Amato MG, et al. Lessons learned from implementation of computerized provider order entry in 5 community hospitals: a quali…
  17. psnet.ahrq.gov/issue/etiology-diagnostic-errors-controlled-trial-system-1-versus-system-2-reasoning
    July 02, 2014 - Study The etiology of diagnostic errors: a controlled trial of System 1 versus System 2 reasoning. Citation Text: Norman GR, Sherbino J, Dore KL, et al. The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning. Acad Med. 2014;89(2):277-84. doi:10.1097…
  18. psnet.ahrq.gov/issue/confidential-reporting-patient-safety-events-primary-care-results-multilevel-classification
    April 07, 2021 - Study Confidential reporting of patient safety events in primary care: results from a multilevel classification of cognitive and system factors. Citation Text: Kostopoulou O, Delaney B. Confidential reporting of patient safety events in primary care: results from a multilevel classific…
  19. psnet.ahrq.gov/issue/what-happened-my-patient-educational-intervention-facilitate-postdischarge-patient-follow
    June 22, 2022 - Commentary What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up. Citation Text: Narayana S, Rajkomar A, Harrison JD, et al. What Happened to My Patient? An Educational Intervention to Facilitate Postdischarge Patient Follow-Up. J Grad Med…
  20. psnet.ahrq.gov/issue/improving-adverse-drug-event-reporting-healthcare-professionals
    April 12, 2019 - Review Improving adverse drug event reporting by healthcare professionals. Citation Text: Shalviri G, Mohebbi N, Mirbaha F, et al. Improving adverse drug event reporting by healthcare professionals. Cochrane Database Syst Rev. 2024;2024(10):CD012594. doi:10.1002/14651858.cd012594.pub2. …