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psnet.ahrq.gov/node/43129/psn-pdf
July 23, 2014 - Use of a daily goals checklist for morning ICU rounds: a
mixed-methods study.
July 23, 2014
Centofanti JE, Duan EH, Hoad NC, et al. Use of a daily goals checklist for morning ICU rounds: a mixed-
methods study. Crit Care Med. 2014;42(8):1797-803. doi:10.1097/CCM.0000000000000331.
https://psnet.ahrq.gov/issue/use-d…
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psnet.ahrq.gov/node/43858/psn-pdf
February 18, 2015 - Hospital system barriers to rapid response team
activation: a cognitive work analysis.
February 18, 2015
Braaten JS. CE: Original research: hospital system barriers to rapid response team activation: a cognitive
work analysis. Am J Nurs. 2015;115(2):22-32; test 33; 47. doi:10.1097/01.NAJ.0000460672.74447.4a.
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psnet.ahrq.gov/node/837811/psn-pdf
August 10, 2022 - Examining the Status of VA’s Electronic Health Record
Modernization Program.
August 10, 2022
US Senate Committee on Veterans Affairs. 117th Cong (2021-2022). (July 20, 2022).
https://psnet.ahrq.gov/issue/examining-status-vas-electronic-health-record-modernization-program
Large-scale electronic health record (EHR) …
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psnet.ahrq.gov/node/837431/psn-pdf
June 15, 2022 - Anesthesiologist group says hospitals can prevent fatal
errors like Vanderbilt's.
June 15, 2022
Clark C. MedPage Today. June 2, 2022
https://psnet.ahrq.gov/issue/anesthesiologist-group-says-hospitals-can-prevent-fatal-errors-vanderbilts
Transparency and discussion of errors is a hallmark of the culture needed to i…
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psnet.ahrq.gov/node/46725/psn-pdf
April 11, 2018 - Are we missing the near misses in the OR?
Underreporting of safety incidents in pediatric surgery.
April 11, 2018
Hamilton EC, Pham DH, Minzenmayer AN, et al. Are we missing the near misses in the OR?-
underreporting of safety incidents in pediatric surgery. J Surg Res. 2018;221:336-342.
doi:10.1016/j.jss.2017.08.…
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psnet.ahrq.gov/node/74011/psn-pdf
October 27, 2021 - Dashboards for visual display of patient safety data: a
systematic review.
October 27, 2021
Murphy DR, Savoy A, Satterly T, et al. Dashboards for visual display of patient safety data: a systematic
review. BMJ Health Care Inform. 2021;28(1):e100437. doi:10.1136/bmjhci-2021-100437.
https://psnet.ahrq.gov/issue/dash…
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psnet.ahrq.gov/node/47122/psn-pdf
June 13, 2018 - Intravenous chemotherapy compounding errors in a
follow-up pan-Canadian observational study.
June 13, 2018
Gilbert RE, Kozak MC, Dobish RB, et al. Intravenous Chemotherapy Compounding Errors in a Follow-Up
Pan-Canadian Observational Study. J Oncol Pract. 2018;14(5):e295-e303. doi:10.1200/JOP.17.00007.
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psnet.ahrq.gov/node/43485/psn-pdf
December 15, 2014 - Implementation of an emergency department sign-out
checklist improves transfer of information at shift change.
December 15, 2014
Dubosh NM, Carney D, Fisher J, et al. Implementation of an emergency department sign-out checklist
improves transfer of information at shift change. J Emerg Med. 2014;47(5):580-5.
doi:10…
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psnet.ahrq.gov/node/44994/psn-pdf
October 11, 2017 - Diagnostic delays and errors in head and neck cancer
patients: opportunities for improvement.
October 11, 2017
Franco J, Elghouche AN, Harris MS, et al. Diagnostic Delays and Errors in Head and Neck Cancer
Patients: Opportunities for Improvement. Am J Med Qual. 2017;32(3):330-335.
doi:10.1177/1062860616638413.
ht…
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psnet.ahrq.gov/node/42681/psn-pdf
December 13, 2013 - Medication reconciliation: reducing risk for medication
misadventure during transition from hospital to assisted
living.
December 13, 2013
Fitzgibbon M, Lorenz R, Lach H. Medication reconciliation: reducing risk for medication misadventure
during transition from hospital to assisted living. J Gerontol Nurs. 2013;3…
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psnet.ahrq.gov/node/41087/psn-pdf
November 26, 2014 - Use of an appreciative inquiry approach to improve
resident sign-out in an era of multiple shift changes.
November 26, 2014
Helms AS, Perez TE, Baltz J, et al. Use of an appreciative inquiry approach to improve resident sign-out in
an era of multiple shift changes. J Gen Intern Med. 2012;27(3):287-91. doi:10.1007/s…
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psnet.ahrq.gov/node/47009/psn-pdf
December 21, 2018 - Perceptions of rounding checklists in the intensive care
unit: a qualitative study.
December 21, 2018
Hallam BD, Kuza CC, Rak K, et al. Perceptions of rounding checklists in the intensive care unit: a
qualitative study. BMJ Qual Saf. 2018;27(10):836-843. doi:10.1136/bmjqs-2017-007218.
https://psnet.ahrq.gov/issue/…
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July 31, 2024 - Simulation to Improve Patient Safety: Getting Started.
July 31, 2024
Deutsch ES, Bajaj K. Simulation To Improve Patient Safety: Getting Started. Rockville, MD: Agency for
Healthcare Research and Quality; July 2024. Publication No. 24-0055.
https://psnet.ahrq.gov/issue/simulation-improve-patient-safety-getting-start…
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psnet.ahrq.gov/node/73853/psn-pdf
September 22, 2021 - Incidence of prescription errors in patients discharged
from the emergency department.
September 22, 2021
Gregory H, Cantley M, Calhoun C, et al. Incidence of prescription errors in patients discharged from the
emergency department. Am J Emerg Med. 2021;46:266-270. doi:10.1016/j.ajem.2020.07.061.
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March 26, 2014 - Recommendations for practitioners and manufacturers to
address system-based causes of vaccine errors.
March 26, 2014
ISMP Medication Safety Alert! Acute care edition. March 13, 2014;19:1-2,4-5.
https://psnet.ahrq.gov/issue/recommendations-practitioners-and-manufacturers-address-system-based-
causes-vaccine-…
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psnet.ahrq.gov/node/42997/psn-pdf
May 28, 2014 - Exploring perinatal shift-to-shift handover communication
and process: an observational study.
May 28, 2014
Poot EP, de Bruijne M, Wouters MGAJ, et al. Exploring perinatal shift-to-shift handover communication and
process: an observational study. J Eval Clin Pract. 2014;20(2):166-75. doi:10.1111/jep.12103.
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September 06, 2017 - Critical Issues in Food Allergy: A National Academies
Consensus Report.
September 6, 2017
Sicherer SH, Allen K, Lack G, et al. Critical Issues in Food Allergy: A National Academies Consensus
Report. Pediatrics. 2017;140(2). doi:10.1542/peds.2017-0194.
https://psnet.ahrq.gov/issue/critical-issues-food-allergy-natio…
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psnet.ahrq.gov/node/48159/psn-pdf
July 31, 2019 - Fatigue in radiology: a fertile area for future research.
July 31, 2019
Taylor-Phillips S, Stinton C. Fatigue in radiology: a fertile area for future research. Br J Radiol.
2019;92(1099):20190043. doi:10.1259/bjr.20190043.
https://psnet.ahrq.gov/issue/fatigue-radiology-fertile-area-future-research
Physician fatigu…
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December 17, 2014 - Facilitating Patient Understanding of Discharge
Instructions: Workshop Summary.
December 17, 2014
Alper J, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health
Practice, Institute of Medicine. Washington, DC: National Academies Press; December 2014. ISBN:
9780309307383.
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May 14, 2014 - Often overlooked problems with handoffs: from the
intensive care unit to the operating room.
May 14, 2014
Evans AS, Yee M-S, Hogue CW. Often overlooked problems with handoffs: from the intensive care unit to
the operating room. Anesth Analg. 2014;118(3):687-9. doi:10.1213/ANE.0000000000000075.
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