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psnet.ahrq.gov/issue/what-scale-prescribing-errors-committed-junior-doctors-systematic-review
January 30, 2013 - Review
What is the scale of prescribing errors committed by junior doctors? A systematic review.
Citation Text:
Ross S, Bond C, Rothnie H, et al. What is the scale of prescribing errors committed by junior doctors? A systematic review. Br J Clin Pharmacol. 2009;67(6):629-40. doi:10.111…
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psnet.ahrq.gov/issue/crew-resource-management-improved-perception-patient-safety-operating-room
April 27, 2010 - Study
Crew resource management improved perception of patient safety in the operating room.
Citation Text:
Gore DC, Powell JM, Baer JG, et al. Crew resource management improved perception of patient safety in the operating room. Am J Med Qual. 2010;25(1):60-3. doi:10.1177/1062860609351…
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psnet.ahrq.gov/issue/medical-record-review-deaths-unexpected-intensive-care-unit-admissions-and-clinician
October 12, 2022 - Study
Medical record review of deaths, unexpected intensive care unit admissions and clinician referrals: detection of adverse events and insight into the system.
Citation Text:
Dunn KL, Reddy P, Moulden A, et al. Medical record review of deaths, unexpected intensive care unit admissio…
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psnet.ahrq.gov/issue/patient-safety-concerns-arising-test-results-return-after-hospital-discharge
January 17, 2012 - Study
Classic
Patient safety concerns arising from test results that return after hospital discharge.
Citation Text:
Roy CL, Poon EG, Karson A, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;…
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psnet.ahrq.gov/issue/pharmacy-leadership-amid-pandemic-maintaining-patient-safety-during-uncertain-times
March 29, 2023 - Commentary
Pharmacy leadership amid the pandemic: maintaining patient safety during uncertain times.
Citation Text:
Derrong Lin I, Hertig JB. Pharmacy leadership amid the pandemic: maintaining patient safety during uncertain times. Hosp Pharm. 2022;57(3):323-328. doi:10.1177/001857872110…
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psnet.ahrq.gov/issue/effect-electronic-sbar-communication-tool-documentation-acute-events-pediatric-intensive-care
August 12, 2015 - Study
The effect of an electronic SBAR communication tool on documentation of acute events in the pediatric intensive care unit.
Citation Text:
Panesar RS, Albert B, Messina C, et al. The Effect of an Electronic SBAR Communication Tool on Documentation of Acute Events in the Pediatric In…
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psnet.ahrq.gov/issue/prevalence-potentially-inappropriate-medication-prescribing-us-nursing-homes-2013-2017
March 27, 2024 - Study
Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017.
Citation Text:
Riester MR, Goyal P, Steinman MA, et al. Prevalence of potentially inappropriate medication prescribing in US nursing homes, 2013-2017. J Gen Intern Med. 2023;38(6):1563-15…
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psnet.ahrq.gov/issue/root-cause-analysis-adverse-events-outpatient-anticoagulation-management-consortium
March 28, 2012 - Study
Root cause analysis of adverse events in an outpatient anticoagulation management consortium.
Citation Text:
Graves CM, Haymart B, Kline-Rogers E, et al. Root Cause Analysis of Adverse Events in an Outpatient Anticoagulation Management Consortium. Jt Comm J Qual Patient Saf. 2017;4…
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psnet.ahrq.gov/issue/nurse-staffing-and-inpatient-hospital-mortality
June 22, 2022 - Study
Classic
Nurse staffing and inpatient hospital mortality.
Citation Text:
Needleman J, Buerhaus P, Pankratz S, et al. Nurse staffing and inpatient hospital mortality. New Engl J Med. 2011;364(11):1037-1045. doi:10.1056/NEJMsa1001025.
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psnet.ahrq.gov/issue/what-we-can-do-about-maternal-mortality-and-how-do-it-quickly
September 01, 2016 - Commentary
Emerging Classic
What we can do about maternal mortality—and how to do it quickly.
Citation Text:
Mann S, Hollier LM, McKay K, et al. What We Can Do about Maternal Mortality - And How to Do It Quickly. New Engl J Med. 2018;379(18):1689-1691. doi:10.10…
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psnet.ahrq.gov/issue/beyond-burnout-physician-wellness-hierarchy-designed-prioritize-interventions-systems-level
July 19, 2023 - Review
Beyond burnout: a physician wellness hierarchy designed to prioritize interventions at the systems level.
Citation Text:
Shapiro DE, Duquette C, Abbott LM, et al. Beyond Burnout: A Physician Wellness Hierarchy Designed to Prioritize Interventions at the Systems Level. Am J Med. 20…
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psnet.ahrq.gov/issue/pictograms-units-and-dosing-tools-and-parent-medication-errors-randomized-study
December 14, 2016 - Study
Pictograms, units and dosing tools, and parent medication errors: a randomized study.
Citation Text:
Yin S, Parker RM, Sanders LM, et al. Pictograms, Units and Dosing Tools, and Parent Medication Errors: A Randomized Study. Pediatrics. 2017;140(1):e20163237. doi:10.1542/peds.2016-3…
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psnet.ahrq.gov/issue/must-we-bust-trust-understanding-how-clinician-patient-relationship-influences-patient
January 11, 2023 - Study
Must we bust the trust?: Understanding how the clinician–patient relationship influences patient engagement in safety.
Citation Text:
Mishra SR, Haldar S, Khelifi M, et al. Must we bust the trust?: Understanding how the clinician–patient relationship influences patient engagement i…
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psnet.ahrq.gov/issue/can-sbar-be-implemented-high-fidelity-and-does-it-improve-communication-between-healthcare
June 22, 2022 - Review
Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review.
Citation Text:
Lo L, Rotteau L, Shojania KG. Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A sys…
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psnet.ahrq.gov/issue/hospital-testing-effectiveness-co-designed-educational-materials-improve-patient-and-visitor
February 28, 2024 - Study
Hospital testing of the effectiveness of co-designed educational materials to improve patient and visitor knowledge and confidence in reporting patient deterioration.
Citation Text:
King L, Belan I, Clark RA, et al. Hospital testing of the effectiveness of co-designed educational m…
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psnet.ahrq.gov/issue/errors-during-resuscitation-impact-perceived-authority-delivery-care
April 03, 2019 - Study
Errors during resuscitation: the impact of perceived authority on delivery of care.
Citation Text:
Delaloye NJ, Tobler K, OʼNeill T, et al. Errors during resuscitation: the impact of perceived authority on delivery of care. J Patient Saf. 2020;16(1). doi:10.1097/pts.000000000000035…
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digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/mollon-b-et-al-2009
January 01, 2009 - Mollon B et al. 2009 "Features predicting the success of computerized decision support for prescribing: a systematic review of randomized controlled trials."
Reference
Mollon B, Chong JJR, Holbrook AM, et al. Features predicting the success of computerized decision support for prescribing: a systemati…
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psnet.ahrq.gov/issue/communication-failure-analysis-prescribers-use-internal-free-text-field-electronic
May 20, 2019 - Study
Communication failure: analysis of prescribers' use of an internal free-text field on electronic prescriptions.
Citation Text:
Ai A, Wong A, Amato MG, et al. Communication failure: analysis of prescribers’ use of an internal free-text field on electronic prescriptions. J Am Med Inf…
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psnet.ahrq.gov/issue/world-health-organization-world-federation-societies-anaesthesiologists-who-wfsa
November 16, 2015 - Commentary
World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia.
Citation Text:
Gelb AW, Morriss WW, Johnson W, et al. World Health Organization-World Federation of Societies of Anaesthesiologis…
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digital.ahrq.gov/organization/st-josephs-community-hospital
January 01, 2023 - St. Joseph's Community Hospital
Improving Patient Safety/Quality with Health Information Technology Implementation
Description
Implemented an Epic health IT system and diffused the system community-wide; identified the prevalence of medication errors, near misses, and preventa…