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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.
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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.
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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.
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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…
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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.
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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.
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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…
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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.
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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…
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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
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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…
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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…
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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.
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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…
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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…
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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…
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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…
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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…
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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…
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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.
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